Provider Demographics
NPI:1467440156
Name:DOMINGUEZ, CARLOS J (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:J
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 1:4306 ALTON RD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2840
Mailing Address - Country:US
Mailing Address - Phone:305-535-3337
Mailing Address - Fax:305-535-3324
Practice Address - Street 1:4306 ALTON RD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2840
Practice Address - Country:US
Practice Address - Phone:305-535-3337
Practice Address - Fax:305-535-3324
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME13580174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD82359Medicare UPIN
FL13697YMedicare ID - Type Unspecified