Basic Information
| Provider Information | |||||||||
| NPI: | 1699796201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 CHILDRENS WAY # MC5075 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589668036 | ||||||||
| FaxNumber: | 8589667433 | ||||||||
| Practice Location | |||||||||
| Address1: | 10690 NE CORNELL RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971249224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038485861 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | G55045 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 2080P0204X | MD26976 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 208000000X | MD26976 | OR | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 298528 | 05 | OR | MEDICAID | 8129355 | 05 | WA | MEDICAID |