Healthcare Provider Details

I. General information

NPI: 1316478241
Provider Name (Legal Business Name): DOMNIQUE S NEWALLO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WOODRUFF CIR NE
ATLANTA GA
30322-4607
US

IV. Provider business mailing address

2825 OAK LAWN AVE UNIT 192749
DALLAS TX
75219-4688
US

V. Phone/Fax

Practice location:
  • Phone: 678-362-2475
  • Fax: 678-807-5414
Mailing address:
  • Phone: 510-683-9500
  • Fax: 877-880-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number81677
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number81677
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number91700
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: