Provider Demographics
NPI:1013125863
Name:DOMANTAY, EDWARD DE GUZMAN
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:DE GUZMAN
Last Name:DOMANTAY
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 1:1114 WILLOW ST
Mailing Address - Street 2:B
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4374
Mailing Address - Country:US
Mailing Address - Phone:510-864-0763
Mailing Address - Fax:
Practice Address - Street 1:1114 WILLOW ST
Practice Address - Street 2:B
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4374
Practice Address - Country:US
Practice Address - Phone:510-864-0763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT8381225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist