Provider Demographics
NPI:1356650535
Name:GERALD H DOMINGUEZ, MD PA
Entity Type:Organization
Organization Name:GERALD H DOMINGUEZ, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-872-7987
Mailing Address - Street 1:4710 N HABANA AVE
Mailing Address - Street 2:STE #201
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
Practice Address - Street 2:STE #201
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0008716207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043129000Medicaid
FLD53589Medicare UPIN