Provider Demographics
NPI:1629504931
Name:SMITH, MATTHEW (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 1:18070 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 15
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4602
Mailing Address - Country:US
Mailing Address - Phone:239-344-4448
Mailing Address - Fax:239-344-4449
Practice Address - Street 1:18900 N TAMIAMI TRL
Practice Address - Street 2:STE A5
Practice Address - City:N FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-7312
Practice Address - Country:US
Practice Address - Phone:239-731-6222
Practice Address - Fax:239-731-6555
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT32480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT32480OtherFLORIDA DEPARTMENT OF HEALTH