Provider Demographics
NPI:1932192978
Name:DOMINGUEZ, LUIS (DO)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ISLAND AVE
Mailing Address - Street 2:APT.1504
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-1347
Mailing Address - Country:US
Mailing Address - Phone:305-672-2908
Mailing Address - Fax:
Practice Address - Street 1:20 ISLAND AVE
Practice Address - Street 2:APT.1504
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-1347
Practice Address - Country:US
Practice Address - Phone:305-672-2908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7516208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000E1429Medicare ID - Type Unspecified
FLG82010Medicare UPIN