Provider Demographics
NPI:1538260302
Name:DUSHUTTLE, DOMINIQUE RENEE (MSPT)
Entity type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:RENEE
Last Name:DUSHUTTLE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MRS
Other - First Name:DOMINIQUE
Other - Middle Name:RENEE
Other - Last Name:KIMBALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:8477 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5028
Mailing Address - Country:US
Mailing Address - Phone:352-382-7214
Mailing Address - Fax:352-382-7781
Practice Address - Street 1:2155 W MUSTANG BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3520
Practice Address - Country:US
Practice Address - Phone:352-746-0019
Practice Address - Fax:352-746-1035
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD199562251X0800X
DEJ1-00016292251X0800X
FLPT36739225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD386902OtherMAMSI/UNITED HEALTHCARE
MDJ5640001OtherBLUE CHOICE
MD61106203OtherCAREFIRST
MD754AATOtherCAREFIRST GROUP #
MD900070997OtherTAX ID #
MD608308600OtherUS DEPARTMENT OF LABOR
MDDC4689OtherRAIL ROAD GROUP #
DE1000037946OtherDELAWARE PHYSICIANS CARE
MDP00200219OtherRAIL ROAD MEDICARE
MD608308600OtherUS DEPARTMENT OF LABOR
DE1000037946OtherDELAWARE PHYSICIANS CARE
MDDC4689OtherRAIL ROAD GROUP #
MD386902OtherMAMSI/UNITED HEALTHCARE