Provider Demographics
NPI:1275910481
Name:DILORENZO, DOMINIQUE (MD)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:DILORENZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:GHANNAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 S ORLANDO AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5543
Mailing Address - Country:US
Mailing Address - Phone:407-409-8807
Mailing Address - Fax:407-557-4885
Practice Address - Street 1:1400 S ORLANDO AVE STE 210
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-5543
Practice Address - Country:US
Practice Address - Phone:407-409-8807
Practice Address - Fax:407-557-4885
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME134088207VX0000X, 207Q00000X, 207VX0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ038804Medicaid