Provider Demographics
NPI:1598765976
Name:SMITH, PHILIP WALTER (PT)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:WALTER
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 1:3670 HENDERSON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4515
Mailing Address - Country:US
Mailing Address - Phone:813-877-6664
Mailing Address - Fax:813-877-8799
Practice Address - Street 1:3670 HENDERSON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4515
Practice Address - Country:US
Practice Address - Phone:813-877-6664
Practice Address - Fax:813-877-8799
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist