Healthcare Provider Details

I. General information

NPI: 1871928853
Provider Name (Legal Business Name): EDWIN GILBERTO DOMINGUEZ SFIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 SMITH RD
NEWPORT RI
02841-1006
US

IV. Provider business mailing address

22 ENTERPRISE CT
NEWPORT RI
02840-1013
US

V. Phone/Fax

Practice location:
  • Phone: 401-841-6128
  • Fax:
Mailing address:
  • Phone: 732-600-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: