Provider Demographics
NPI:1275998098
Name:SMITH, JOSEPH (PHD, ATC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6238 14TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 RAMONA RD
Practice Address - Street 2:
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-8135
Practice Address - Country:US
Practice Address - Phone:808-341-7262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA040422172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer