Provider Demographics
NPI:1164408084
Name:SMITH, RANDALL DON (RPT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:DON
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4551 NORTH DAVIS HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503
Mailing Address - Country:US
Mailing Address - Phone:850-473-2772
Mailing Address - Fax:850-474-4123
Practice Address - Street 1:4551 NORTH DAVIS HWY
Practice Address - Street 2:SUITE C
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503
Practice Address - Country:US
Practice Address - Phone:850-473-2772
Practice Address - Fax:850-474-4123
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT3301225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7437OtherBCBS FLORIDA
AL59197541OtherBCBS ALABAMA
FL5789020001Medicare NSC
FLAK275ZMedicare PIN
AL59197541OtherBCBS ALABAMA