Provider Demographics
NPI:1548770977
Name:DOMINGUEZ, FERMIN ELIZALDE III
Entity Type:Individual
Prefix:
First Name:FERMIN
Middle Name:ELIZALDE
Last Name:DOMINGUEZ
Suffix:III
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 1:9219 CENTRO GRANDE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-1291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3463 MAGIC DR STE T21
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3621
Practice Address - Country:US
Practice Address - Phone:210-614-8101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX753893163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Multi-Specialty