Provider Demographics
NPI:1770615528
Name:DOMINGO, CARLOS B (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:B
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8415 CLIFFTHORNE WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-8410
Mailing Address - Country:US
Mailing Address - Phone:614-505-0482
Mailing Address - Fax:
Practice Address - Street 1:1970 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1363
Practice Address - Country:US
Practice Address - Phone:740-344-2452
Practice Address - Fax:740-344-7305
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35089303208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35089303OtherOHIO STATE MEDICAL LICENS