Provider Demographics
NPI:1982602819
Name:SMITH, MARK LEONARD (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEONARD
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 1:118 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1677
Mailing Address - Country:US
Mailing Address - Phone:717-231-8539
Mailing Address - Fax:717-231-8588
Practice Address - Street 1:118 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1677
Practice Address - Country:US
Practice Address - Phone:717-231-8539
Practice Address - Fax:717-231-8588
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008187L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA089232MV7Medicare ID - Type UnspecifiedMC PROVIDER NUMBER