Provider Demographics
NPI:1609840248
Name:DOMINGO, MOISES B
Entity Type:Individual
Prefix:DR
First Name:MOISES
Middle Name:B
Last Name:DOMINGO
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 15040
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-0040
Mailing Address - Country:US
Mailing Address - Phone:812-476-1367
Mailing Address - Fax:812-477-4153
Practice Address - Street 1:20 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2453
Practice Address - Country:US
Practice Address - Phone:618-252-5126
Practice Address - Fax:618-252-0135
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010329662085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036066172Medicaid
IN100319850Medicaid
IN281360FMedicare PIN
IN100319850Medicaid
C43312Medicare UPIN