Healthcare Provider Details

I. General information

NPI: 1942735964
Provider Name (Legal Business Name): THOMAS SMITH JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8185 E ROSKO CT
FLORAL CITY FL
34436-2069
US

IV. Provider business mailing address

8185 E ROSKO CT
FLORAL CITY FL
34436-2069
US

V. Phone/Fax

Practice location:
  • Phone: 352-587-3323
  • Fax:
Mailing address:
  • Phone: 352-587-3323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9382122
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: