Provider Demographics
NPI:1104146513
Name:SMITH, JOHN VICTOR JR (PTA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:VICTOR
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
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Mailing Address - Street 1:105 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-1200
Mailing Address - Country:US
Mailing Address - Phone:580-795-3301
Mailing Address - Fax:580-795-7307
Practice Address - Street 1:1203 E 22ND AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-1719
Practice Address - Country:US
Practice Address - Phone:813-229-6901
Practice Address - Fax:813-229-0091
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPTA21084225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA12084OtherSTATE OF FLORIDA