Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PE0004X | Emergency Medical Services | 4269 | CT |
N | 207PP0204X | Pediatric Emergency Physician | 4269 | CT |
N | 207Q00000X | Family Doctor | 4269 | CT |
N | 207R00000X | Internist | 4269 | CT |
N | 111NI0900X | Internist | 4269 | CT |
NPI | 1568945004 |
---|---|
Provider Name | Thomas Joseph Dominguez IV |
First Address | Fort Pierce, FL 34950-4800 |
Second Address | Fort Pierce, FL 34950-4800 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/09/2018 |
Last Update Date | 25/10/2021 |