Provider Demographics
NPI:1871554774
Name:DOMINGUEZ, JOSE CARLOS JR (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:CARLOS
Last Name:DOMINGUEZ
Suffix:JR
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 1:3645 MADACA LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2048
Mailing Address - Country:US
Mailing Address - Phone:813-969-0116
Mailing Address - Fax:813-969-3794
Practice Address - Street 1:3645 MADACA LN
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2048
Practice Address - Country:US
Practice Address - Phone:813-969-0116
Practice Address - Fax:813-969-3794
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00555091207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059950600Medicaid
FL15065Medicare ID - Type Unspecified
F30656Medicare UPIN