Provider Demographics
NPI:1104864768
Name:DOMINGUEZ, CARLOS LORENZO (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:LORENZO
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4876 RED BRICK RUN
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-7108
Mailing Address - Country:US
Mailing Address - Phone:386-789-8544
Mailing Address - Fax:321-249-9432
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:321-249-9432
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072352207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252750200Medicaid
FL32987AMedicare ID - Type Unspecified
FLG35467Medicare UPIN