Provider Demographics
NPI:1871928853
Name:DOMINGUEZ, EDWIN GILBERTO (SFIDC)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:GILBERTO
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 ENTERPRISE CT
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-1013
Mailing Address - Country:US
Mailing Address - Phone:732-600-6575
Mailing Address - Fax:
Practice Address - Street 1:43 SMITH RD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02841-1006
Practice Address - Country:US
Practice Address - Phone:401-841-6128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman