Provider Demographics
NPI:1215566609
Name:HADDAD, DOMINIC JAMIL (DO)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:JAMIL
Last Name:HADDAD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 BEAM AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1126
Mailing Address - Country:US
Mailing Address - Phone:651-232-7000
Mailing Address - Fax:
Practice Address - Street 1:1575 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1126
Practice Address - Country:US
Practice Address - Phone:651-232-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN74531207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine