Healthcare Provider Details

I. General information

NPI: 1932192978
Provider Name (Legal Business Name): LUIS DOMINGUEZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 ISLAND AVE APT.1504
MIAMI BEACH FL
33139-1347
US

IV. Provider business mailing address

20 ISLAND AVE APT.1504
MIAMI BEACH FL
33139-1347
US

V. Phone/Fax

Practice location:
  • Phone: 305-672-2908
  • Fax:
Mailing address:
  • Phone: 305-672-2908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS7516
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: