Healthcare Provider Details

I. General information

NPI: 1679597850
Provider Name (Legal Business Name): JERRY RICHARD SMITH PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BARBEL PLZ #8 NEW QUARTER
ST THOMAS VI
00802-4600
US

IV. Provider business mailing address

PO BOX 302178
ST THOMAS VI
00803-2178
US

V. Phone/Fax

Practice location:
  • Phone: 340-779-4678
  • Fax: 340-715-4678
Mailing address:
  • Phone: 340-779-4678
  • Fax: 340-715-4678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number121
License Number StateVI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT22484
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: