Healthcare Provider Details

I. General information

NPI: 1104146513
Provider Name (Legal Business Name): JOHN VICTOR SMITH JR. PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 E 22ND AVE
TAMPA FL
33605-1719
US

IV. Provider business mailing address

105 N 5TH AVE
MADILL OK
73446-1200
US

V. Phone/Fax

Practice location:
  • Phone: 813-229-6901
  • Fax: 813-229-0091
Mailing address:
  • Phone: 580-795-3301
  • Fax: 580-795-7307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA21084
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: