Provider Demographics
NPI:1801131503
Name:SMITH, MICHAEL TYLER (DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TYLER
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4058
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-4058
Mailing Address - Country:US
Mailing Address - Phone:410-315-9080
Mailing Address - Fax:410-315-9012
Practice Address - Street 1:2430 BROAD AVE
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2262
Practice Address - Country:US
Practice Address - Phone:410-308-3543
Practice Address - Fax:410-308-4663
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24264225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist