Healthcare Provider Details

I. General information

NPI: 1013508878
Provider Name (Legal Business Name): EASTERN MEDICAL FORT MEYERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 SW 24 ST #202
MIAMI FL
33165
US

IV. Provider business mailing address

8900 SW 24 ST #202
MIAMI FL
33165
US

V. Phone/Fax

Practice location:
  • Phone: 305-901-9551
  • Fax: 786-618-5219
Mailing address:
  • Phone: 305-901-9551
  • Fax: 786-618-5219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTIAN S DOMINGUEZ
Title or Position: C.E.O
Credential:
Phone: 305-901-9551