Provider Demographics
NPI:1720277452
Name:MCDONALD, KENNETH IRVING (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:IRVING
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W NORTH BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5000
Mailing Address - Country:US
Mailing Address - Phone:352-728-6636
Mailing Address - Fax:352-787-4522
Practice Address - Street 1:600 W NORTH BLVD STE D
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5000
Practice Address - Country:US
Practice Address - Phone:352-728-6636
Practice Address - Fax:352-787-4522
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 14744225100000X
FLPT34821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ08904ZOtherBLUE SHIELD
CAZZZ08904ZOtherBLUE SHIELD