Healthcare Provider Details

I. General information

NPI: 1396775334
Provider Name (Legal Business Name): CARMEN LETICIA DOMINGUEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 BROAD ST STE 200
SUMTER SC
29150-4167
US

IV. Provider business mailing address

P.O. BOX 9671
DAYTONA BEACH FL
32120-9671
US

V. Phone/Fax

Practice location:
  • Phone: 803-773-5227
  • Fax: 803-418-0202
Mailing address:
  • Phone: 386-676-7130
  • Fax: 386-676-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number95305
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number25MA07822000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: