Provider Demographics
NPI:1316478241
Name:NEWALLO, DOMNIQUE S (MD)
Entity type:Individual
Prefix:
First Name:DOMNIQUE
Middle Name:S
Last Name:NEWALLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2825 OAK LAWN AVE UNIT 192749
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4688
Mailing Address - Country:US
Mailing Address - Phone:510-683-9500
Mailing Address - Fax:877-880-2039
Practice Address - Street 1:100 WOODRUFF CIR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4607
Practice Address - Country:US
Practice Address - Phone:678-362-2475
Practice Address - Fax:678-807-5414
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA81677207U00000X, 2085N0904X
SC917002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology