Healthcare Provider Details

I. General information

NPI: 1083111587
Provider Name (Legal Business Name): DOMINIC ANDRE JOSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 BREMO RD
RICHMOND VA
23226-1907
US

IV. Provider business mailing address

PO BOX 749112
ATLANTA GA
30374-9112
US

V. Phone/Fax

Practice location:
  • Phone: 804-285-2011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101275505
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: