Provider Demographics
NPI:1801835962
Name:DOMINGUEZ, NOEL R (MD)
Entity Type:Individual
Prefix:
First Name:NOEL
Middle Name:R
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:P O BOX 210
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185
Mailing Address - Country:US
Mailing Address - Phone:931-296-4225
Mailing Address - Fax:931-296-4218
Practice Address - Street 1:209 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185
Practice Address - Country:US
Practice Address - Phone:931-296-4225
Practice Address - Fax:931-296-4218
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2021-10-07
Deactivation Date:2021-07-09
Deactivation Code:
Reactivation Date:2021-10-07
Provider Licenses
StateLicense IDTaxonomies
FLME57103207R00000X
TNMD0000019861207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL81977OtherBC INDIV PROV #
FL99006Medicare ID - Type UnspecifiedMEDICARE GROUP #
FLE15085Medicare UPIN