Provider Demographics
NPI:1699930057
Name:MCDONALD, GENNE DETTENAU (PT)
Entity type:Individual
Prefix:
First Name:GENNE
Middle Name:DETTENAU
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 357279
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32635-7279
Mailing Address - Country:US
Mailing Address - Phone:352-373-7984
Mailing Address - Fax:352-332-3812
Practice Address - Street 1:3919 W NEWBERRY RD
Practice Address - Street 2:SUITE 4
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2355
Practice Address - Country:US
Practice Address - Phone:352-373-7984
Practice Address - Fax:352-332-3812
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT9145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAN021ZMedicare PIN