Healthcare Provider Details

I. General information

NPI: 1851705826
Provider Name (Legal Business Name): DOMINGO MOLINA IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE ST K-415 KENTUCKY CLINIC
LEXINGTON KY
40536-0284
US

IV. Provider business mailing address

140 W MAIN ST STE 100
SPRINGFIELD OH
45502-1369
US

V. Phone/Fax

Practice location:
  • Phone: 959-323-5533
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number35.138325
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: