Healthcare Provider Details

I. General information

NPI: 1477248706
Provider Name (Legal Business Name): GINA DOMINGUEZ CASTILLO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 ACADEMY ST STE 101
CANTON GA
30114-3008
US

IV. Provider business mailing address

115 ACADEMY ST STE 101
CANTON GA
30114-3008
US

V. Phone/Fax

Practice location:
  • Phone: 470-389-4970
  • Fax: 470-401-1089
Mailing address:
  • Phone: 470-389-4970
  • Fax: 470-401-1089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number113630
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: