Provider Demographics
NPI:1508935321
Name:SMITH, JOHNNY L (MS)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23077 GREENFIELD RD
Mailing Address - Street 2:STE 250
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3709
Mailing Address - Country:US
Mailing Address - Phone:248-557-7336
Mailing Address - Fax:248-557-4544
Practice Address - Street 1:23077 GREENFIELD RD
Practice Address - Street 2:STE 250
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3709
Practice Address - Country:US
Practice Address - Phone:248-557-7336
Practice Address - Fax:248-557-4544
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001786225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM841700004Medicare ID - Type Unspecified