Healthcare Provider Details

I. General information

NPI: 1083725139
Provider Name (Legal Business Name): DOMINADOR T. PERIDO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 SUNSET
ELKHART KS
67950-0997
US

IV. Provider business mailing address

PO BOX 997
ELKHART KS
67950-0997
US

V. Phone/Fax

Practice location:
  • Phone: 620-697-2155
  • Fax: 620-697-4275
Mailing address:
  • Phone: 620-697-2155
  • Fax: 620-697-4275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberKS04-16343
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberKS04-16343
License Number StateKS

VIII. Authorized Official

Name: DR. DOMINADOR T. PERIDO
Title or Position: OWNER
Credential: M.D.
Phone: 620-697-2155