Provider Demographics
NPI:1083703490
Name:SMITH, DEREK MILES (PT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:MILES
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 1:4780 N JOSEY LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4615
Mailing Address - Country:US
Mailing Address - Phone:972-492-1334
Mailing Address - Fax:972-492-5174
Practice Address - Street 1:4780 N JOSEY LN
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4615
Practice Address - Country:US
Practice Address - Phone:972-492-1334
Practice Address - Fax:972-492-5174
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1140028225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D5829OtherMEDICARE PART B - PRIOR TO 2/1/11
TX8T3800OtherBCBS
TXP00954365OtherRAILROAD MEDICARE
TXTXB121221OtherMEDICARE PART B - EFFECT 3/3/11
TX854T69OtherBC/BS TX - EFFECT 02/01/2011