Provider Demographics
NPI:1700868841
Name:DOMINGO, ALBERT T (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:T
Last Name:DOMINGO
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 1:3120 PARKWAY ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-3981
Mailing Address - Country:US
Mailing Address - Phone:330-452-9460
Mailing Address - Fax:330-452-9520
Practice Address - Street 1:3120 PARKWAY ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-3981
Practice Address - Country:US
Practice Address - Phone:330-452-9460
Practice Address - Fax:330-452-9520
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049267D207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1376559799OtherGROUP NPI
OH0544370Medicaid
OH3600701Medicare PIN
OH1376559799OtherGROUP NPI
OHDO0541022Medicare ID - Type Unspecified