Provider Demographics
NPI:1609963321
Name:SMITH, JOHAN PHILSON (MSPT)
Entity Type:Individual
Prefix:
First Name:JOHAN
Middle Name:PHILSON
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 680312
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-0312
Mailing Address - Country:US
Mailing Address - Phone:305-965-1990
Mailing Address - Fax:
Practice Address - Street 1:1201 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1624
Practice Address - Country:US
Practice Address - Phone:305-324-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04541R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist