Provider Demographics
NPI:1184872483
Name:SMITH, MATTHEW W (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:W
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 1:7065 AIRWAYS BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5873
Mailing Address - Country:US
Mailing Address - Phone:662-349-8997
Mailing Address - Fax:662-349-8987
Practice Address - Street 1:7065 AIRWAYS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5873
Practice Address - Country:US
Practice Address - Phone:662-349-8997
Practice Address - Fax:662-349-8987
Is Sole Proprietor?:No
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3511225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist