Healthcare Provider Details

I. General information

NPI: 1205949104
Provider Name (Legal Business Name): MARISELA DOMINGUEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 SPRING HILL DR
SPRING HILL FL
34606-4562
US

IV. Provider business mailing address

14690 SPRING HILL DRIVE SUITE 100
SPRING HILL FL
34609
US

V. Phone/Fax

Practice location:
  • Phone: 352-688-8116
  • Fax: 352-686-9477
Mailing address:
  • Phone: 352-799-0046
  • Fax: 352-606-2857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-091349
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME102787
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME102787
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: