Provider Demographics
NPI:1144538364
Name:HUMBERTO A DOMINGUEZ MD PA
Entity type:Organization
Organization Name:HUMBERTO A DOMINGUEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HUMBERTO
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-668-4411
Mailing Address - Street 1:70 FOX RIDGE CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-2752
Mailing Address - Country:US
Mailing Address - Phone:386-668-4411
Mailing Address - Fax:386-668-8688
Practice Address - Street 1:70 FOX RIDGE CT
Practice Address - Street 2:SUITE A
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2752
Practice Address - Country:US
Practice Address - Phone:386-668-4411
Practice Address - Fax:386-668-8688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME29577261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038066100Medicaid
FLD56577Medicare UPIN
FL038066100Medicaid