Healthcare Provider Details

I. General information

NPI: 1760155873
Provider Name (Legal Business Name): DOMINIQUE MEKKAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DOMINIQUE GODDARD-HARTE MD

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CHAMBER CENTER DR
FT. MITCHELL KY
41017-1686
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-3114
  • Fax: 859-578-2156
Mailing address:
  • Phone: 859-341-3114
  • Fax: 859-578-2156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58818
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: