Provider Demographics
NPI:1922082882
Name:DOMINGO, PATRICK J (OD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-2920
Mailing Address - Country:US
Mailing Address - Phone:904-996-0200
Mailing Address - Fax:904-641-7166
Practice Address - Street 1:11900 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-2920
Practice Address - Country:US
Practice Address - Phone:904-996-0200
Practice Address - Fax:904-641-7166
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3445152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6205551Z00Medicaid
U82991Medicare UPIN
FL6205551Z00Medicaid