Basic Information
| Provider Information | |||||||||
| NPI: | 1083703490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | MILES | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4780 N JOSEY LN | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750104615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724921334 | ||||||||
| FaxNumber: | 9724925174 | ||||||||
| Practice Location | |||||||||
| Address1: | 4780 N JOSEY LN | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750104615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724921334 | ||||||||
| FaxNumber: | 9724925174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 05/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1140028 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | 1140028 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 8D5829 | 01 | TX | MEDICARE PART B - PRIOR TO 2/1/11 | OTHER | 8T3800 | 01 | TX | BCBS | OTHER | P00954365 | 01 | TX | RAILROAD MEDICARE | OTHER | TXB121221 | 01 | TX | MEDICARE PART B - EFFECT 3/3/11 | OTHER | 854T69 | 01 | TX | BC/BS TX - EFFECT 02/01/2011 | OTHER |