Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 20055 | MD |
NPI | 1053385559 |
---|---|
Provider Name | Jose Antolin Dominguez |
First Address | Jacksonville, FL 32214-5005 |
Second Address | Jacksonville, FL 32214-5005 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/02/2006 |
Last Update Date | 08/07/2007 |