Provider Demographics
NPI:1083065130
Name:DOMINGUEZ, IVAN (SPT ATC LAT)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:SPT ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3698 CHAMBERS PASS BLDG 3611
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7766
Mailing Address - Country:US
Mailing Address - Phone:210-916-5658
Mailing Address - Fax:210-271-0830
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-5658
Practice Address - Fax:210-271-0830
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1335011225100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty