Provider Demographics
NPI:1346376803
Name:DOMINGO-FORASTE, DIANNE (MD)
Entity type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:
Last Name:DOMINGO-FORASTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2256 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-1243
Mailing Address - Country:US
Mailing Address - Phone:323-268-8511
Mailing Address - Fax:323-268-0717
Practice Address - Street 1:2256 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-1243
Practice Address - Country:US
Practice Address - Phone:323-268-8511
Practice Address - Fax:323-268-0717
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53343207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ70430ZMedicaid
CAZZZ70430ZMedicaid
CAW924Medicare ID - Type Unspecified