Healthcare Provider Details

I. General information

NPI: 1801184601
Provider Name (Legal Business Name): BENJAMIN RUSSELL SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 09/10/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 SW WASHINGTON ST
PORTLAND OR
97205-2327
US

IV. Provider business mailing address

1312 SW WASHINGTON ST
PORTLAND OR
97205-2327
US

V. Phone/Fax

Practice location:
  • Phone: 650-937-9774
  • Fax:
Mailing address:
  • Phone: 650-937-9774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number185564
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: