Provider Demographics
NPI:1144969395
Name:DOMINIC, JERRY LORREN (MD(MBBS IN INDIA))
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:LORREN
Last Name:DOMINIC
Suffix:
Gender:M
Credentials:MD(MBBS IN INDIA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE-JACKSON M
Mailing Address - Street 2:1611 NW 12 AVENUE
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136
Mailing Address - Country:US
Mailing Address - Phone:305-585-1280
Mailing Address - Fax:305-585-1280
Practice Address - Street 1:UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE-JACKSON M
Practice Address - Street 2:1611 NW 12 AVENUE
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136
Practice Address - Country:US
Practice Address - Phone:305-585-1280
Practice Address - Fax:305-585-1280
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2023-07-03
Deactivation Date:2023-03-01
Deactivation Code:
Reactivation Date:2023-07-03
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program