Provider Demographics
NPI:1306698188
Name:SMITH, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:5439 MOUNTAIN VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-4640
Mailing Address - Country:US
Mailing Address - Phone:173-780-2510
Mailing Address - Fax:
Practice Address - Street 1:4726 SANTA MONICA AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-2209
Practice Address - Country:US
Practice Address - Phone:737-802-5103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY85271225800000X
225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist