Healthcare Provider Details

I. General information

NPI: 1508972563
Provider Name (Legal Business Name): ANGELA P DOMINIQUE D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3524 DECATUR HWY SUITE 301
FULTONDALE AL
35068-1366
US

IV. Provider business mailing address

3524 DECATUR HWY SUITE 301
FULTONDALE AL
35068-1366
US

V. Phone/Fax

Practice location:
  • Phone: 205-631-3699
  • Fax: 205-631-7325
Mailing address:
  • Phone: 205-631-3699
  • Fax: 205-631-7325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number180
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: