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General NPI Number Information
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NPI Number | 1144538364
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Entity Type | Organization
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Legal Business Name | HUMBERTO A DOMINGUEZ MD PA
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Dates
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Enumeration Date | 09/22/2010
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Last Update Date | 06/20/2011
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Provider Practice Location Address
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Address Line | 70 FOX RIDGE CT SUITE A
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City | DEBARY
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State | FL
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Zip | 32713-2752
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Country | US
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Telephone | 386-668-4411
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Fax | 386-668-8688
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Provider Business Mailing Address
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Address Line | 70 FOX RIDGE CT SUITE A
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City | DEBARY
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State | FL
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Zip | 32713-2752
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Country | US
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Telephone | 386-668-4411
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Fax | 386-668-8688
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Authorized Official
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Title or Position | OWNER
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Name | HUMBERTO A DOMINGUEZ
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Credential | MD
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Telephone | 386-668-4411
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | ME29577
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License Number State | FL
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