MEDICARE: DOMA MD LLC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1790330397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMA MD LLC

Provider Business Mailing Address
First Line	:	4000 N 37TH AVE
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-1927
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	440 E SAMPLE RD STE 107
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33064-4432
Country	:	US
Telephone Number	:	754-205-2496
Fax Number	:	754-205-5156

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. OSVALDO MARTINEZ
Credential	:
Telephone Number	:	954-918-4533

Provider Enumeration Date	:	08/09/2019
Last Update Date	:	08/09/2019

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Directions to “DOMA MD LLC ” Practice Location

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