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General NPI Number Information
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NPI Number | 1194228924
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Entity Type | Individual
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Provider Name | DOMINIQUE BROUTIN MD
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Gender | Female
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Dates
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Enumeration Date | 03/18/2018
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Last Update Date | 07/19/2023
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Provider Practice Location Address
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Address Line | 3113 LAWTON RD STE 100
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City | ORLANDO
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State | FL
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Zip | 32803-3519
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Country | US
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Telephone | 407-894-3241
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Fax | 407-896-9863
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Provider Business Mailing Address
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Address Line | 3113 LAWTON RD STE 100
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City | ORLANDO
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State | FL
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Zip | 32803-3519
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Country | US
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Telephone | 407-894-3241
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Fax | 407-896-9863
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number | ME163046
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 261QS1000X
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Taxonomy Name | Student Health Clinic/Center
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License Number |
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License Number State |
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