Provider Demographics
NPI:1770587693
Name:DOMINGO, EVILLO M (MD)
Entity type:Individual
Prefix:DR
First Name:EVILLO
Middle Name:M
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 NEAL ZICK RD
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:OH
Mailing Address - Zip Code:44890-9282
Mailing Address - Country:US
Mailing Address - Phone:567-224-0854
Mailing Address - Fax:
Practice Address - Street 1:25 SPRING ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:OH
Practice Address - Zip Code:44865
Practice Address - Country:US
Practice Address - Phone:419-687-5781
Practice Address - Fax:419-687-5018
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-4369-D207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2083972Medicaid
OH2083972Medicaid
OH4132293Medicare PIN