Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 1140028 | TX |
N | 2251X0800X | Physical Therapist - Orthopedic | 1140028 | TX |
NPI | 1083703490 |
---|---|
Provider Name | Derek Miles Smith |
First Address | Carrollton, TX 75010-4615 |
Second Address | Carrollton, TX 75010-4615 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 22/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
854T69 | BC/BS TX - EFFECT 02/01/2011 (01) | TX |
8D5829 | MEDICARE PART B - PRIOR TO 2/1/11 (01) | TX |
8T3800 | BCBS (01) | TX |
P00954365 | RAILROAD MEDICARE (01) | TX |
TXB121221 | MEDICARE PART B - EFFECT 3/3/11 (01) | TX |