=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043443377
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TATIANA RAMIREZ DOMINGUEZ MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2009
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 621 S NEW BALLAS RD STE 7011B
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-8275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-251-6840
-----------------------------------------------------
Fax | 314-251-7249
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 621 S NEW BALLAS RD STE 7011B
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-8275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-251-6840
-----------------------------------------------------
Fax | 314-251-7249
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | 2019007247
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------