Provider Demographics
NPI:1689294803
Name:DOMINGUEZ, OMAR FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:FERNANDO
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 1:1200 MEMORIAL DRIVE
Mailing Address - Street 2:HAMILTON MEDICAL CENTER, ATTN: RESIDENCY PROGRAM
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720
Mailing Address - Country:US
Mailing Address - Phone:706-272-6132
Mailing Address - Fax:
Practice Address - Street 1:1200 MEMORIAL DRIVE
Practice Address - Street 2:HAMILTON MEDICAL CENTER, ATTN: RESIDENCY PROGRAM
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720
Practice Address - Country:US
Practice Address - Phone:706-272-6132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA96719207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine