Provider Demographics
NPI:1730496845
Name:SMITH, COREY J (DPT, OCS, MTC)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT, OCS, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 OLD LIVERPOOL RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6033
Mailing Address - Country:US
Mailing Address - Phone:315-429-2004
Mailing Address - Fax:
Practice Address - Street 1:604 OLD LIVERPOOL RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6033
Practice Address - Country:US
Practice Address - Phone:315-429-2004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0373302251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic