Healthcare Provider Details

I. General information

NPI: 1255451712
Provider Name (Legal Business Name): FELIPE EMILIO DOMINGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 VENTURE LN STE. 108
MELBOURNE FL
32934-8172
US

IV. Provider business mailing address

3030 VENTURE LN STE 108
MELBOURNE FL
32934-8172
US

V. Phone/Fax

Practice location:
  • Phone: 321-253-5197
  • Fax: 321-253-5199
Mailing address:
  • Phone: 321-253-5197
  • Fax: 321-253-5199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberME48985
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberME 48985
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: