Healthcare Provider Details

I. General information

NPI: 1992797435
Provider Name (Legal Business Name): NOEL E SANTO DOMINGO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 SOUTHPOINT BLVD STE B
PETALUMA CA
94954-1495
US

IV. Provider business mailing address

3536 MENDOCINO AVE STE 200
SANTA ROSA CA
95403-3634
US

V. Phone/Fax

Practice location:
  • Phone: 707-778-8421
  • Fax: 707-778-1702
Mailing address:
  • Phone: 707-573-6166
  • Fax: 707-573-6165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG79253
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: