Provider Demographics
NPI:1558370577
Name:SMITH, VINCENT PAUL (PT)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:PAUL
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 1:1940 BEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-5707
Mailing Address - Country:US
Mailing Address - Phone:817-283-9435
Mailing Address - Fax:817-571-4198
Practice Address - Street 1:1940 BEDFORD RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5707
Practice Address - Country:US
Practice Address - Phone:817-283-9435
Practice Address - Fax:817-571-4198
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1047272225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87724301Medicaid
TX8D1372Medicare ID - Type UnspecifiedTARRANT COUNTY MEDICARE #
TX00129YMedicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
TX8D2547Medicare ID - Type UnspecifiedDALLAS COUNTY MEDICARE#
TX87724301Medicaid