Provider Demographics
NPI:1922239219
Name:SMITH, JOHN D (MBA, MSED, ATC LAT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:MBA, MSED, ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-3460
Mailing Address - Country:US
Mailing Address - Phone:440-354-1942
Mailing Address - Fax:
Practice Address - Street 1:10 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-3460
Practice Address - Country:US
Practice Address - Phone:440-354-1942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-0010162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer