Basic Information
| Provider Information | |||||||||
| NPI: | 1033310412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARCANTONIO | ||||||||
| FirstName: | DOMENICA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1090 NE 84TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331383420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524011000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1431 SW 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524011000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 03/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME111770 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 0101245230 | VA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 390200000X | 0116018214 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 004444400 | 05 | FL | MEDICAID | 14J65 | 01 | FL | BCBS | OTHER | 1033310412 | 05 | VA | MEDICAID |