Healthcare Provider Details

I. General information

NPI: 1275910481
Provider Name (Legal Business Name): DOMINIQUE DILORENZO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DOMINIQUE GHANNAM

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S ORLANDO AVE STE 210
WINTER PARK FL
32789-5543
US

IV. Provider business mailing address

1400 S ORLANDO AVE STE 210
WINTER PARK FL
32789-5543
US

V. Phone/Fax

Practice location:
  • Phone: 407-409-8807
  • Fax: 407-557-4885
Mailing address:
  • Phone: 407-409-8807
  • Fax: 407-557-4885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberME134088
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME134088
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: