Provider Demographics
NPI:1760592497
Name:SMITH, TIM
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7807 HARDWICK DR
Mailing Address - Street 2:#123
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-6292
Mailing Address - Country:US
Mailing Address - Phone:314-984-2200
Mailing Address - Fax:
Practice Address - Street 1:9550 US HIGHWAY 19
Practice Address - Street 2:STE D-9
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-4664
Practice Address - Country:US
Practice Address - Phone:727-847-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA 1665OtherLICENSE#