Provider Demographics
NPI:1154784304
Name:DOMINGUEZ-PANTOJA, GABRIEL JOSE
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:JOSE
Last Name:DOMINGUEZ-PANTOJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S MCKINLEY ST APT 4311
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-2069
Mailing Address - Country:US
Mailing Address - Phone:989-429-3177
Mailing Address - Fax:
Practice Address - Street 1:601 E ALTAMONTE DR
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4802
Practice Address - Country:US
Practice Address - Phone:407-303-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-11820207P00000X
390200000X
FLME139214207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty