Provider Demographics
NPI:1619943990
Name:DOMINGUEZ, RICARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
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 1:15211 FINTRY PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1424
Mailing Address - Country:US
Mailing Address - Phone:305-819-3077
Mailing Address - Fax:305-827-0636
Practice Address - Street 1:777 E 25TH ST
Practice Address - Street 2:SUITE 303
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3825
Practice Address - Country:US
Practice Address - Phone:305-693-7412
Practice Address - Fax:305-693-7416
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87966208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH96477Medicare UPIN
FLU1631Medicare ID - Type Unspecified