Provider Demographics
NPI:1649673898
Name:SMITH, TODD (PA)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 SE 3RD AVE
Mailing Address - Street 2:THIRD FLOOR PBO
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2564
Mailing Address - Country:US
Mailing Address - Phone:954-355-4665
Mailing Address - Fax:
Practice Address - Street 1:1625 SE 3RD AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2521
Practice Address - Country:US
Practice Address - Phone:954-355-4665
Practice Address - Fax:954-355-4881
Is Sole Proprietor?:No
Enumeration Date:2014-10-02
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9108182363AS0400X
WI1003363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015493500Medicaid