Provider Demographics
NPI:1720336837
Name:DOMINO, STANLEY
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:DOMINO
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 1:10502 SATELLITE BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-8479
Mailing Address - Country:US
Mailing Address - Phone:407-850-9141
Mailing Address - Fax:407-850-9687
Practice Address - Street 1:10502 SATELLITE BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-8479
Practice Address - Country:US
Practice Address - Phone:407-850-9141
Practice Address - Fax:407-850-9687
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIM4999390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program