Healthcare Provider Details

I. General information

NPI: 1184891830
Provider Name (Legal Business Name): PATRICK L DOMINGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 W GRANT ST STE 117
ORLANDO FL
32806-3909
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7172
US

V. Phone/Fax

Practice location:
  • Phone: 866-400-3376
  • Fax: 407-770-0182
Mailing address:
  • Phone: 866-400-3376
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME154324
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: