Basic Information
| Provider Information | |||||||||
| NPI: | 1538260302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUSHUTTLE | ||||||||
| FirstName: | DOMINIQUE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIMBALL | ||||||||
| OtherFirstName: | DOMINIQUE | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8477 S SUNCOAST BLVD | ||||||||
| Address2: | |||||||||
| City: | HOMOSASSA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344465028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523827214 | ||||||||
| FaxNumber: | 3523827781 | ||||||||
| Practice Location | |||||||||
| Address1: | 2155 W MUSTANG BLVD | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344653520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527460019 | ||||||||
| FaxNumber: | 3527461035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 02/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 19956 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 2251X0800X | J1-0001629 | DE | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | PT36739 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 386902 | 01 | MD | MAMSI/UNITED HEALTHCARE | OTHER | J5640001 | 01 | MD | BLUE CHOICE | OTHER | 61106203 | 01 | MD | CAREFIRST | OTHER | 754AAT | 01 | MD | CAREFIRST GROUP # | OTHER | 900070997 | 01 | MD | TAX ID # | OTHER | 608308600 | 01 | MD | US DEPARTMENT OF LABOR | OTHER | DC4689 | 01 | MD | RAIL ROAD GROUP # | OTHER | 1000037946 | 01 | DE | DELAWARE PHYSICIANS CARE | OTHER | P00200219 | 01 | MD | RAIL ROAD MEDICARE | OTHER |