Provider Demographics
NPI:1528044211
Name:DONATO, EDSEN (PT, DSC, OCS, CHT)
Entity Type:Individual
Prefix:
First Name:EDSEN
Middle Name:
Last Name:DONATO
Suffix:
Gender:M
Credentials:PT, DSC, OCS, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 NW HAWTHORNE AVE
Mailing Address - Street 2:#103
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1257
Mailing Address - Country:US
Mailing Address - Phone:541-476-2502
Mailing Address - Fax:541-476-2397
Practice Address - Street 1:1701 NW HAWTHORNE AVE
Practice Address - Street 2:#103
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1257
Practice Address - Country:US
Practice Address - Phone:541-476-2502
Practice Address - Fax:541-476-2397
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4306225100000X, 2251H1200X
2251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269923Medicaid
ORR131982Medicare PIN