Provider Demographics
NPI:1770576464
Name:PERIDO, DOMINADOR T JR
Entity type:Individual
Prefix:DR
First Name:DOMINADOR
Middle Name:T
Last Name:PERIDO
Suffix:JR
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:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:KS
Mailing Address - Zip Code:67950-0997
Mailing Address - Country:US
Mailing Address - Phone:620-697-2155
Mailing Address - Fax:620-697-4275
Practice Address - Street 1:411 SUNSET
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:KS
Practice Address - Zip Code:67950-0997
Practice Address - Country:US
Practice Address - Phone:620-697-2155
Practice Address - Fax:620-697-4275
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS0416343208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100085400AMedicaid
KS100085400AMedicaid
040168Medicare ID - Type Unspecified