Provider Demographics
NPI:1730452970
Name:CARLOS L DOMINGUEZ MD PA
Entity type:Organization
Organization Name:CARLOS L DOMINGUEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-789-8544
Mailing Address - Street 1:1857 PROVIDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-3811
Mailing Address - Country:US
Mailing Address - Phone:386-789-8544
Mailing Address - Fax:386-951-4809
Practice Address - Street 1:1857 PROVIDENCE BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-3811
Practice Address - Country:US
Practice Address - Phone:386-789-8544
Practice Address - Fax:386-951-4809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072352207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252750200Medicaid
FL252750200Medicaid