Provider Demographics
NPI:1740242023
Name:DOMINGO, MELANIA B (MD)
Entity Type:Individual
Prefix:DR
First Name:MELANIA
Middle Name:B
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8912
Mailing Address - Country:US
Mailing Address - Phone:912-537-9334
Mailing Address - Fax:912-537-0019
Practice Address - Street 1:510 MAPLE DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8912
Practice Address - Country:US
Practice Address - Phone:912-537-9334
Practice Address - Fax:912-537-0019
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017919207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000014671AMedicaid
GA08BDBGMMedicare ID - Type Unspecified