Provider Demographics
NPI:1255451712
Name:DOMINGUEZ, FELIPE EMILIO
Entity type:Individual
Prefix:
First Name:FELIPE
Middle Name:EMILIO
Last Name:DOMINGUEZ
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 1:3030 VENTURE LN
Mailing Address - Street 2:STE 108
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-8172
Mailing Address - Country:US
Mailing Address - Phone:321-253-5197
Mailing Address - Fax:321-253-5199
Practice Address - Street 1:3030 VENTURE LN
Practice Address - Street 2:STE. 108
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-8172
Practice Address - Country:US
Practice Address - Phone:321-253-5197
Practice Address - Fax:321-253-5199
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48985207ZC0006X
FLME 48985291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL83082Medicare UPIN
FL09921WMedicare PIN