Provider Demographics
NPI:1780818682
Name:DOMINGUEZ, SERGIO
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MADISON AVE FL 8
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-1676
Mailing Address - Country:US
Mailing Address - Phone:212-684-0099
Mailing Address - Fax:
Practice Address - Street 1:60 MADISON AVE FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1676
Practice Address - Country:US
Practice Address - Phone:212-684-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014543225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist