Healthcare Provider Details

I. General information

NPI: 1174412266
Provider Name (Legal Business Name): THOMAS SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

IV. Provider business mailing address

4120 SW 149TH TER
MIRAMAR FL
33027-3336
US

V. Phone/Fax

Practice location:
  • Phone: 571-231-2198
  • Fax:
Mailing address:
  • Phone: 954-540-5804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: