Healthcare Provider Details

I. General information

NPI: 1487578043
Provider Name (Legal Business Name): DR. JORGE ANDRES DOMINGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9767 SW 72ND ST
MIAMI FL
33173-4615
US

IV. Provider business mailing address

15528 SW 172ND TER
MIAMI FL
33187-1360
US

V. Phone/Fax

Practice location:
  • Phone: 786-785-8990
  • Fax:
Mailing address:
  • Phone: 305-527-0599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT45096
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: