Healthcare Provider Details

I. General information

NPI: 1033851472
Provider Name (Legal Business Name): CARLOS BRYAN DOMINGUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 W ORANGE BLOSSOM TRL
APOPKA FL
32712-3482
US

IV. Provider business mailing address

6101 BLUE LAGOON DR STE 200
MIAMI FL
33126-3168
US

V. Phone/Fax

Practice location:
  • Phone: 407-884-2952
  • Fax: 407-884-9352
Mailing address:
  • Phone: 844-630-0700
  • Fax: 877-374-1924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberME180588
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: