Provider Demographics
NPI:1801069893
Name:DOMINGO, ANTHONY CENIZA (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:CENIZA
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 1:7048 W 17TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4419
Mailing Address - Country:US
Mailing Address - Phone:305-794-2025
Mailing Address - Fax:
Practice Address - Street 1:1400 NE MIAMI GARDENS DR STE 104
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-4843
Practice Address - Country:US
Practice Address - Phone:305-814-8637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110741207RE0101X
MI4301103949207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2051234Medicare PIN
MI1801069893Medicaid