Provider Demographics
NPI:1851393946
Name:DOMINGO, JUAN (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
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 1:900 SW PINE ISLAND RD
Mailing Address - Street 2:UNIT 208
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-1979
Mailing Address - Country:US
Mailing Address - Phone:239-673-9861
Mailing Address - Fax:239-673-9886
Practice Address - Street 1:900 SW PINE ISLAND RD
Practice Address - Street 2:UNIT 208
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-1979
Practice Address - Country:US
Practice Address - Phone:239-673-9861
Practice Address - Fax:239-673-9886
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME52059207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4909698OtherCIGNA
FL5194010OtherAETNA
FL048503900Medicaid
FL0405271OtherUNITED HEALTH CARE
FL07319OtherBC/BS
FL07319OtherBC/BS
FL010054023Medicare PIN