Provider Demographics
NPI:1043310303
Name:SMITH, DAN MARK (PT)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:MARK
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
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 516
Mailing Address - Street 2:
Mailing Address - City:PLUMMER
Mailing Address - State:ID
Mailing Address - Zip Code:83851-0516
Mailing Address - Country:US
Mailing Address - Phone:208-686-1931
Mailing Address - Fax:208-686-9061
Practice Address - Street 1:1111 A STREET
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851
Practice Address - Country:US
Practice Address - Phone:208-686-1931
Practice Address - Fax:208-686-9061
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist