Provider Demographics
NPI:1558534545
Name:DOMINGO, GELENIS CALZADILLA (MD)
Entity Type:Individual
Prefix:
First Name:GELENIS
Middle Name:CALZADILLA
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GELENIS
Other - Middle Name:
Other - Last Name:CALZADILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5644
Mailing Address - Fax:954-276-0668
Practice Address - Street 1:20801 BISCAYNE BOULEVARD
Practice Address - Street 2:SUITE 200
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1422
Practice Address - Country:US
Practice Address - Phone:954-265-4325
Practice Address - Fax:305-935-3186
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110846207RH0003X, 207RH0003X
IL036132324390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004108900Medicaid
FL14H6DOtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL004108900Medicaid