Provider Demographics
NPI:1578023842
Name:DOMINGUEZ, LISETTE (DO)
Entity type:Individual
Prefix:DR
First Name:LISETTE
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
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:PO BOX 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-0727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 N PICKAWAY ST STE 200
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1447
Practice Address - Country:US
Practice Address - Phone:614-533-5500
Practice Address - Fax:614-533-0103
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO6775207R00000X, 2084N0400X
FLOS171462084N0400X
OH34.0172882084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine