Provider Demographics
NPI:1285653022
Name:DOMINGUEZ, GERALD HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:HENRY
Last Name:DOMINGUEZ
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 1:4710 N HABANA AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7146
Mailing Address - Country:US
Mailing Address - Phone:813-872-7987
Mailing Address - Fax:813-875-1832
Practice Address - Street 1:4710 N HABANA AVE STE 201
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7146
Practice Address - Country:US
Practice Address - Phone:813-872-7987
Practice Address - Fax:813-875-1832
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0008617207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD53589Medicare UPIN