MEDICARE: DOMINADOR G GOBALEZA III MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	D5D218	MD

General Provider Information

NPI Number	:	1407829153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINADOR G GOBALEZA III MD

Provider Business Mailing Address
First Line	:	2817 REILLY ROAD
Second Line	:	MCXC-COD CREDENTIALS WOMACK ARMY MEDICAL CENTER
City	:	FORT BRAGG
State	:	NC
Zip	:	28310
Country	:	US
Telephone Number	:	910-907-8922
Fax Number	:	910-907-6069

Provider Business Practice Location Address
First Line	:	2817 REILLY ROAD DDBH 6 NORTH
Second Line	:	MCXC-COD CREDENTIALS WOMACK ARMY MEDICAL CENTER
City	:	FORT BRAGG
State	:	NC
Zip	:	28310
Country	:	US
Telephone Number	:	910-907-6825
Fax Number	:	910-907-8521

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2006
Last Update Date	:	07/08/2007

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