Provider Demographics
NPI:1871874974
Name:FELIPE E. DOMINGUEZ, MD, PA
Entity type:Organization
Organization Name:FELIPE E. DOMINGUEZ, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FELIPE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-795-1321
Mailing Address - Street 1:14040 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958
Mailing Address - Country:US
Mailing Address - Phone:772-581-0890
Mailing Address - Fax:772-581-0591
Practice Address - Street 1:3030 VENTURE LANE
Practice Address - Street 2:STE 108
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934
Practice Address - Country:US
Practice Address - Phone:321-253-5197
Practice Address - Fax:321-253-5199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 48985291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory