Provider Demographics
NPI:1043332901
Name:MCDONALD, BART WILLIAM (MPT)
Entity Type:Individual
Prefix:
First Name:BART
Middle Name:WILLIAM
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 FLANDRO DR
Mailing Address - Street 2:190
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4940
Mailing Address - Country:US
Mailing Address - Phone:208-233-2248
Mailing Address - Fax:208-233-0219
Practice Address - Street 1:1800 FLANDRO DR
Practice Address - Street 2:190
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-4940
Practice Address - Country:US
Practice Address - Phone:208-233-2248
Practice Address - Fax:208-233-0219
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5744703OtherFIRST HEALTH
IDPT1555OtherTRICARE
ID807400900Medicaid
IDP00320548OtherBLUE SHIELD MEDICARE ADV
IDTD646OtherBCID
IDPT1555OtherTRICARE