Provider Demographics
NPI:1194041582
Name:DOMINGUEZ VALLEJOS, LUIS AUGUSTO (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:AUGUSTO
Last Name:DOMINGUEZ VALLEJOS
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:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1700 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3509
Practice Address - Country:US
Practice Address - Phone:941-917-4896
Practice Address - Fax:941-917-6884
Is Sole Proprietor?:No
Enumeration Date:2010-04-11
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114375208M00000X, 207R00000X
TXP5269207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014791600Medicaid
WVDO7418991Medicare PIN