Provider Demographics
NPI:1063131373
Name:SMITH, DAJAN TYRONE
Entity type:Individual
Prefix:MR
First Name:DAJAN
Middle Name:TYRONE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8714 SANDY PLAINS DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-8615
Mailing Address - Country:US
Mailing Address - Phone:813-777-4453
Mailing Address - Fax:
Practice Address - Street 1:8714 SANDY PLAINS DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-8615
Practice Address - Country:US
Practice Address - Phone:813-777-4453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL524680146L00000X
FLS530178802140172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic