Healthcare Provider Details

I. General information

NPI: 1508145251
Provider Name (Legal Business Name): ROLANDO DOMINGUEZ MUSTAFA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 W DUVAL ST
LAKE CITY FL
32055-5806
US

IV. Provider business mailing address

437 SW ROSEMARY DR
LAKE CITY FL
32024-6715
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-3500
  • Fax:
Mailing address:
  • Phone: 973-610-6389
  • Fax: 386-719-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME123013
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME123013
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: