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General NPI Number Information
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NPI Number | 1316478241
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Entity Type | Individual
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Provider Name | DOMNIQUE S NEWALLO M.D.
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Gender | Female
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Dates
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Enumeration Date | 03/22/2017
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Last Update Date | 09/11/2024
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Provider Practice Location Address
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Address Line | 100 WOODRUFF CIR NE
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City | ATLANTA
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State | GA
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Zip | 30322-4607
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Country | US
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Telephone | 678-362-2475
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Fax | 678-807-5414
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Provider Business Mailing Address
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Address Line | 2825 OAK LAWN AVE UNIT 192749
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City | DALLAS
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State | TX
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Zip | 75219-4688
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Country | US
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Telephone | 510-683-9500
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Fax | 877-880-2039
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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 | 207U00000X
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Taxonomy Name | Nuclear Medicine Physician
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License Number | 81677
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 2085N0904X
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Taxonomy Name | Nuclear Radiology Physician
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License Number | 81677
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 91700
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License Number State | SC
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