Provider Demographics
NPI:1871945352
Name:TAMAYO, DOMENIC ALFONSO
Entity type:Individual
Prefix:
First Name:DOMENIC
Middle Name:ALFONSO
Last Name:TAMAYO
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 1:5542 PRANZ PL
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-1568
Mailing Address - Country:US
Mailing Address - Phone:541-513-5489
Mailing Address - Fax:
Practice Address - Street 1:3515 KINSROW AVE APT 406
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8019
Practice Address - Country:US
Practice Address - Phone:541-726-8198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR500695639172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500705909Medicaid
OR500695639Medicaid