Provider Demographics
NPI:1750773917
Name:SMITH, DOUGLAS (MS, ATC)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 EAGLES NEST RD
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-8937
Mailing Address - Country:US
Mailing Address - Phone:740-453-4603
Mailing Address - Fax:
Practice Address - Street 1:1701 BLUE AVE
Practice Address - Street 2:ZANESVILLE HIGH SCHOOL
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701
Practice Address - Country:US
Practice Address - Phone:740-588-4012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT01502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer