Provider Demographics
NPI:1376032474
Name:SMITH, MATTHEW THOMAS (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 DRAKE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6201
Mailing Address - Country:US
Mailing Address - Phone:321-749-8154
Mailing Address - Fax:
Practice Address - Street 1:12421 SAN JOSE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8662
Practice Address - Country:US
Practice Address - Phone:904-292-0195
Practice Address - Fax:904-292-0566
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT33420225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist