Healthcare Provider Details

I. General information

NPI: 1568695344
Provider Name (Legal Business Name): PETER JOHN SMITH I DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 08/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 FAIRHARBOR DR
PATCHOGUE NY
11772-3335
US

IV. Provider business mailing address

167 FAIRHARBOR DR
PATCHOGUE NY
11772-3335
US

V. Phone/Fax

Practice location:
  • Phone: 631-988-4527
  • Fax: 631-714-5906
Mailing address:
  • Phone: 631-988-4527
  • Fax: 631-714-5906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number025539
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: