Provider Demographics
NPI:1508972563
Name:DOMINIQUE, ANGELA P (DPM)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:P
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:3524 DECATUR HWY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FULTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35068-1366
Mailing Address - Country:US
Mailing Address - Phone:205-631-3699
Mailing Address - Fax:205-631-7325
Practice Address - Street 1:3524 DECATUR HWY
Practice Address - Street 2:SUITE 301
Practice Address - City:FULTONDALE
Practice Address - State:AL
Practice Address - Zip Code:35068-1366
Practice Address - Country:US
Practice Address - Phone:205-631-3699
Practice Address - Fax:205-631-7325
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2016-06-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AL180213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL480026565OtherRAILROAD MEDICARE
AL000060837Medicaid
AL27-10123OtherUNITED HEALTHCARE
AL1536404OtherUMWA H&R FUNDS
ALU71228OtherVIVA HEALTH
AL510-60837OtherBLUE CROSS BLUE SHIELD AL
ALU71228Medicare UPIN
AL480026565OtherRAILROAD MEDICARE
ALU71228OtherVIVA HEALTH
AL27-10123OtherUNITED HEALTHCARE
AL510-60837OtherBLUE CROSS BLUE SHIELD AL
AL1536404OtherUMWA H&R FUNDS
AL000060837Medicare ID - Type Unspecified
AL000044894Medicare ID - Type Unspecified
AL000045057Medicare ID - Type Unspecified
AL510-44894OtherBLUE CROSS BLUE SHIELD AL
AL480026565OtherRAILROAD MEDICARE