1255451712 NPI number — FELIPE EMILIO DOMINGUEZ

Table of content: FELIPE EMILIO DOMINGUEZ (NPI 1255451712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255451712 NPI number — FELIPE EMILIO DOMINGUEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMINGUEZ
Provider First Name:
FELIPE
Provider Middle Name:
EMILIO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255451712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3030 VENTURE LN
Provider Second Line Business Mailing Address:
STE 108
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32934-8172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-253-5197
Provider Business Mailing Address Fax Number:
321-253-5199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3030 VENTURE LN
Provider Second Line Business Practice Location Address:
STE. 108
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32934-8172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-253-5197
Provider Business Practice Location Address Fax Number:
321-253-5199
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZC0006X , with the licence number:  ME48985 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: ME 48985 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 052769600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com