Provider Demographics
NPI:1669415162
Name:SMITH, DAVID (PT, CMDT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, CMDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 N WICKHAM RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7321
Mailing Address - Country:US
Mailing Address - Phone:321-701-4020
Mailing Address - Fax:321-701-4009
Practice Address - Street 1:5000 N WICKHAM RD STE 107
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7321
Practice Address - Country:US
Practice Address - Phone:321-701-4020
Practice Address - Fax:321-701-4009
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020385000Medicaid
FLK9101OtherHARBOR CITY PHYSICAL THERAPY GROUP NUMBER
FLPT-20472OtherSTATE OF FL. PT LICENSE
FL020385000Medicaid