Provider Demographics
NPI:1033205091
Name:MESIDOR, DOMINIQUE (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:
Last Name:MESIDOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 59TH ST W
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-4616
Mailing Address - Country:US
Mailing Address - Phone:941-794-5621
Mailing Address - Fax:941-761-1532
Practice Address - Street 1:2010 59TH ST W
Practice Address - Street 2:SUITE 2200
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4616
Practice Address - Country:US
Practice Address - Phone:941-794-5621
Practice Address - Fax:941-761-1532
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00863982086S0127X
GA0445392086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU1254XOtherMEDICARE
FL267667200Medicaid