Healthcare Provider Details

I. General information

NPI: 1194228924
Provider Name (Legal Business Name): DOMINIQUE BROUTIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2018
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 LAWTON RD STE 100
ORLANDO FL
32803-3519
US

IV. Provider business mailing address

3113 LAWTON RD STE 100
ORLANDO FL
32803-3519
US

V. Phone/Fax

Practice location:
  • Phone: 407-894-3241
  • Fax: 407-896-9863
Mailing address:
  • Phone: 407-894-3241
  • Fax: 407-896-9863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberME163046
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: