Provider Demographics
NPI:1609256072
Name:DOMINGUEZ, IVAN (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
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 1:14421 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-3114
Mailing Address - Country:US
Mailing Address - Phone:786-508-9713
Mailing Address - Fax:
Practice Address - Street 1:680 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024
Practice Address - Country:US
Practice Address - Phone:954-981-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME134038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty