1538260302 NPI number — MS. DOMINIQUE RENEE DUSHUTTLE MSPT

Table of content: ADAM WILLAMETZ (NPI 1821829342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538260302 NPI number — MS. DOMINIQUE RENEE DUSHUTTLE MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUSHUTTLE
Provider First Name:
DOMINIQUE
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIMBALL
Provider Other First Name:
DOMINIQUE
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538260302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8477 S SUNCOAST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMOSASSA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34446-5028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-382-7214
Provider Business Mailing Address Fax Number:
352-382-7781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2155 W MUSTANG BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEVERLY HILLS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34465-3520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-746-0019
Provider Business Practice Location Address Fax Number:
352-746-1035
Provider Enumeration Date:
09/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  19956 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: J1-0001629 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT36739 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 386902 . This is a "MAMSI/UNITED HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: J5640001 . This is a "BLUE CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 61106203 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 754AAT . This is a "CAREFIRST GROUP #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 900070997 . This is a "TAX ID #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 608308600 . This is a "US DEPARTMENT OF LABOR" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: DC4689 . This is a "RAIL ROAD GROUP #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1000037946 . This is a "DELAWARE PHYSICIANS CARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: P00200219 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".