Provider Demographics
NPI:1467694521
Name:DOMINGUEZ, DAVID E (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:E
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 1:141 COCONUT DR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2607
Mailing Address - Country:US
Mailing Address - Phone:321-610-8939
Mailing Address - Fax:321-622-8728
Practice Address - Street 1:141 COCONUT DR
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-2607
Practice Address - Country:US
Practice Address - Phone:321-610-8939
Practice Address - Fax:321-622-8728
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110378207X00000X, 2086S0127X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003772300Medicaid
FLFE468YMedicare PIN
FLFE468ZMedicare PIN