Healthcare Provider Details

I. General information

NPI: 1669460986
Provider Name (Legal Business Name): BROCK LEWIS SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3251 N MCMULLEN BOOTH RD STE 301
CLEARWATER FL
33761-2022
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 727-669-5300
  • Fax: 727-669-5366
Mailing address:
  • Phone: 727-315-7469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA02632
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9117281
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: