Provider Demographics
NPI:1902239791
Name:SMITH, KENNETH O JR (DPT)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:O
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1241
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75151-1241
Mailing Address - Country:US
Mailing Address - Phone:903-874-7433
Mailing Address - Fax:903-874-6292
Practice Address - Street 1:1026 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-3702
Practice Address - Country:US
Practice Address - Phone:903-874-7433
Practice Address - Fax:903-874-6295
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1234566225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist