Provider Demographics
NPI:1386737872
Name:BORDEAUX, DONNA MARIA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIA
Last Name:BORDEAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:
Other - Last Name:DUTTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 LINCOLN STREET
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011
Mailing Address - Country:US
Mailing Address - Phone:207-729-1164
Mailing Address - Fax:207-725-0905
Practice Address - Street 1:22 LINCOLN STREET
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011
Practice Address - Country:US
Practice Address - Phone:207-729-1164
Practice Address - Fax:207-725-0905
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT651225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME122120099Medicaid
MEMM2165Medicare PIN