Provider Demographics
NPI:1174787683
Name:SMITH, DOMINIC R (PT)
Entity type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3796
Mailing Address - Country:US
Mailing Address - Phone:818-901-6600
Mailing Address - Fax:818-997-7826
Practice Address - Street 1:6815 NOBLE AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3796
Practice Address - Country:US
Practice Address - Phone:818-901-6600
Practice Address - Fax:818-997-7826
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT345012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT34501OtherLICENSE