Provider Demographics
NPI:1275910481
Name:DILORENZO, DOMINIQUE (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:DILORENZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:GHANNAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7975 LAKE UNDERHILL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-8204
Mailing Address - Country:US
Mailing Address - Phone:407-303-6830
Mailing Address - Fax:407-303-6839
Practice Address - Street 1:7975 LAKE UNDERHILL RD STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8204
Practice Address - Country:US
Practice Address - Phone:407-303-6830
Practice Address - Fax:407-303-6839
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN57354207Q00000X, 207V00000X
FLME134088207VX0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ038804Medicaid