Provider Demographics
NPI:1235326984
Name:DOMINGO, MAXFELONILO A (MD)
Entity Type:Individual
Prefix:
First Name:MAXFELONILO
Middle Name:A
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:308 W HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4716
Mailing Address - Country:US
Mailing Address - Phone:352-726-8353
Mailing Address - Fax:352-726-5038
Practice Address - Street 1:760 SE 5TH TERRACE
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4852
Practice Address - Country:US
Practice Address - Phone:352-795-4165
Practice Address - Fax:352-795-3659
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0043605207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000755600Medicaid
FL11379665OtherCAQH
FL77940OtherMEDICARE GROUP ID
FLCF1416OtherMEDICARE RR GROUP
FLME43605OtherSTATE MEDICAL LICENSE
FL77940OtherBCBS OF FL GROUP ID
FL79947OtherBS OF FL
FL06004119OtherRAILROAD MEDICARE
FL269859500OtherMEDICAID GROUP
FL592123944OtherCIGNA
FL77940OtherBCBS OF FL GROUP ID
FLD67381Medicare UPIN