Provider Demographics
NPI:1013508878
Name:EASTERN MEDICAL FORT MEYERS
Entity Type:Organization
Organization Name:EASTERN MEDICAL FORT MEYERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-901-9551
Mailing Address - Street 1:8900 SW 24 ST #202
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165
Mailing Address - Country:US
Mailing Address - Phone:305-901-9551
Mailing Address - Fax:786-618-5219
Practice Address - Street 1:8900 SW 24 ST #202
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165
Practice Address - Country:US
Practice Address - Phone:305-901-9551
Practice Address - Fax:786-618-5219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty