Provider Demographics
NPI:1659479921
Name:SMITH, JEREMY ALLEN (PT)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:ALLEN
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 1:12416 66TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-3430
Mailing Address - Country:US
Mailing Address - Phone:727-547-4700
Mailing Address - Fax:727-394-8661
Practice Address - Street 1:12416 66TH ST STE A
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-3430
Practice Address - Country:US
Practice Address - Phone:727-547-4700
Practice Address - Fax:727-394-8661
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 22390225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8249Medicare ID - Type UnspecifiedGROUP ID