Provider Demographics
NPI:1710775499
Name:SMITH, TOMMY III
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:
Last Name:SMITH
Suffix:III
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 1:15678 CRESTWOOD DR APT 217
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-5616
Mailing Address - Country:US
Mailing Address - Phone:925-325-9108
Mailing Address - Fax:
Practice Address - Street 1:1923 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4601
Practice Address - Country:US
Practice Address - Phone:925-930-0545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54007225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant