Provider Demographics
NPI:1003850801
Name:MACDONALD, GARRY R (OTRL)
Entity Type:Individual
Prefix:MR
First Name:GARRY
Middle Name:R
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:OTRL
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 648
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34755-0648
Mailing Address - Country:US
Mailing Address - Phone:352-404-4523
Mailing Address - Fax:352-243-8367
Practice Address - Street 1:1705 E HIGHWAY 50 STE 1
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5186
Practice Address - Country:US
Practice Address - Phone:352-404-4523
Practice Address - Fax:352-243-8367
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10697225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU5700ZMedicare ID - Type Unspecified