Provider Demographics
NPI:1891831004
Name:DOMINGUEZ, MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:
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 1:1540 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-7801
Mailing Address - Country:US
Mailing Address - Phone:305-532-4122
Mailing Address - Fax:305-534-9665
Practice Address - Street 1:1540 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-7801
Practice Address - Country:US
Practice Address - Phone:305-532-4122
Practice Address - Fax:305-534-9665
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0029578207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040100500Medicaid
FL93485Medicare ID - Type Unspecified
FL040100500Medicaid