Basic Information
| Provider Information | |||||||||
| NPI: | 1205949104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | MARISELA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14690 SPRING HILL DRIVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527990046 | ||||||||
| FaxNumber: | 3526062857 | ||||||||
| Practice Location | |||||||||
| Address1: | 5350 SPRING HILL DR | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346064562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526888116 | ||||||||
| FaxNumber: | 3526869477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-091349 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME102787 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | ME102787 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 000431600 | 05 | FL | MEDICAID |