MEDICARE: DIANA SANTO DOMINGO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	997612	CA
2	207N00000X	Dermatology Physician	C168169	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C168169	OTHER	CA	STATE MEDICAL LICENSE

General Provider Information

NPI Number	:	1437350709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA SANTO DOMINGO M.D.

Provider Business Mailing Address
First Line	:	325 DISTEL CIR
Second Line	:
City	:	LOS ALTOS
State	:	CA
Zip	:	94022-1408
Country	:	US
Telephone Number	:	707-521-4495
Fax Number	:	707-573-5421

Provider Business Practice Location Address
First Line	:	3883 AIRWAY DR STE 203
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-1671
Country	:	US
Telephone Number	:	707-521-4495
Fax Number	:	707-573-5421

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	09/22/2023

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