Provider Demographics
NPI:1396775334
Name:DOMINGUEZ, CARMEN LETICIA (MD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:LETICIA
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 9671
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9671
Mailing Address - Country:US
Mailing Address - Phone:386-676-7130
Mailing Address - Fax:386-676-7125
Practice Address - Street 1:320 NORTH CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2733
Practice Address - Country:US
Practice Address - Phone:386-238-3226
Practice Address - Fax:386-238-3260
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07822000207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1396775334OtherTRICARE
FLP01061992OtherRAILROAD
FL01076OtherBCBS
FL278835700Medicaid
FL278835700Medicaid