Provider Demographics
NPI:1194228924
Name:BROUTIN, DOMINIQUE (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:BROUTIN
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 1:3113 LAWTON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3519
Mailing Address - Country:US
Mailing Address - Phone:407-894-3241
Mailing Address - Fax:407-896-9863
Practice Address - Street 1:3113 LAWTON RD STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3519
Practice Address - Country:US
Practice Address - Phone:407-894-3241
Practice Address - Fax:407-896-9863
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-18
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME163046207RE0101X
261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118632800Medicaid