Provider Demographics
NPI:1659337731
Name:DOMINGUEZ, ROBERTO V (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:V
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 1:2914 N BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-1208
Mailing Address - Country:US
Mailing Address - Phone:813-228-7696
Mailing Address - Fax:813-228-0677
Practice Address - Street 1:2914 N BOULEVARD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-1208
Practice Address - Country:US
Practice Address - Phone:813-228-7696
Practice Address - Fax:813-228-0677
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0070106208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2513081-00Medicaid
FL2755877OtherAETNA
FLB217748OtherWELLCARE (NON-PAR)
FL2305989OtherUNITED HEALTHCARE
FL32985OtherBLUE CROSS
FL4333872005OtherCIGNA
FL2513081-00Medicaid
FL4333872005OtherCIGNA