Provider Demographics
NPI:1508565847
Name:ROMAN DOMINGUEZ, ANGEL OMAR
Entity Type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:OMAR
Last Name:ROMAN DOMINGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:BARCELONETA
Mailing Address - State:PR
Mailing Address - Zip Code:00617-0764
Mailing Address - Country:US
Mailing Address - Phone:787-473-1786
Mailing Address - Fax:
Practice Address - Street 1:55 AVE LUNA
Practice Address - Street 2:
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674-4819
Practice Address - Country:US
Practice Address - Phone:787-473-1786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR23633208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice