Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PY7379 | FL |
Y | 103TC0700X | Clinical Psychologist | PY7379 | FL |
NPI | 1003951344 |
---|---|
Provider Name | Dr. Angelo Sebastian Domingo |
First Address | Parrish, FL 34219-4417 |
Second Address | Parrish, FL 34219-4417 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/02/2007 |
Last Update Date | 20/04/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
AA931 | MEDICARE PTAN (01) |