Provider Demographics
NPI:1255095766
Name:DOMINGUEZ BAZART, ISMAEL
Entity type:Individual
Prefix:
First Name:ISMAEL
Middle Name:
Last Name:DOMINGUEZ BAZART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15070 SW 68TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2007
Mailing Address - Country:US
Mailing Address - Phone:786-370-0636
Mailing Address - Fax:
Practice Address - Street 1:15070 SW 68TH LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2007
Practice Address - Country:US
Practice Address - Phone:786-370-0636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician