Provider Demographics
NPI:1912634163
Name:DOMINGUEZ, OBDELIS
Entity Type:Individual
Prefix:
First Name:OBDELIS
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 SW 133RD CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-7133
Mailing Address - Country:US
Mailing Address - Phone:786-447-2902
Mailing Address - Fax:
Practice Address - Street 1:2860 SW 133RD CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-7133
Practice Address - Country:US
Practice Address - Phone:786-447-2902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021188363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care