Healthcare Provider Details

I. General information

NPI: 1407855513
Provider Name (Legal Business Name): MARTIN HENNINGER DOMINGUEZ DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 WATERFORD LAKE DR STE 103
MIDLOTHIAN VA
23112-3994
US

IV. Provider business mailing address

3200 LADY MARIAN LN
MIDLOTHIAN VA
23113-1178
US

V. Phone/Fax

Practice location:
  • Phone: 804-249-8277
  • Fax: 804-249-9690
Mailing address:
  • Phone: 804-677-2551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2305004476
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: