Provider Demographics
NPI:1871025668
Name:SMITH, MARK ROBERT (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
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 1:11448 PRINCESSA LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4054
Mailing Address - Country:US
Mailing Address - Phone:904-274-1704
Mailing Address - Fax:
Practice Address - Street 1:11448 PRINCESSA LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4054
Practice Address - Country:US
Practice Address - Phone:904-274-1704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23938225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT23938OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH