Healthcare Provider Details

I. General information

NPI: 1629301528
Provider Name (Legal Business Name): MARTIN JAY SMILKSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS HOSPITAL RD
PORTLAND OR
97239-2964
US

IV. Provider business mailing address

2536 NW OVERTON ST
PORTLAND OR
97210-2441
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax:
Mailing address:
  • Phone: 503-227-1814
  • Fax: 503-224-3479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number17517
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: