Provider Demographics
NPI:1588770655
Name:SMITH, IAN A (MD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:2500 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6015
Practice Address - Country:US
Practice Address - Phone:541-706-7715
Practice Address - Fax:541-706-7742
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042448207RC0200X, 207RI0200X, 207RP1001X
ORMD205339207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3529SMOtherBLUE SHIELD
WA0039581OtherL&I
WA8411282Medicaid
WAP00341222OtherRAILROAD MEDICARE
WA8411282Medicaid
H68956Medicare UPIN