Provider Demographics
NPI:1245526268
Name:DOMINGO, CARMINA AMOR TAN (DO)
Entity type:Individual
Prefix:
First Name:CARMINA
Middle Name:AMOR TAN
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:4205 WESTBROOK DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4124
Practice Address - Country:US
Practice Address - Phone:630-961-4150
Practice Address - Fax:630-961-4151
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022034192084N0400X
IL036-1590012084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology