Provider Demographics
NPI:1861574824
Name:SMITH, BRENDA PEARL (MD, FACEP)
Entity type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:PEARL
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD, FACEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1253
Mailing Address - Fax:
Practice Address - Street 1:400 9TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-7398
Practice Address - Country:US
Practice Address - Phone:541-997-8412
Practice Address - Fax:541-902-1695
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00049058207P00000X
ORMD22482207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8257354Medicaid
OR286469Medicaid
ORH61397Medicare UPIN
WA8257354Medicaid