Provider Demographics
NPI:1386347474
Name:TADIESSE DOMGUIA, ELIE
Entity type:Individual
Prefix:MR
First Name:ELIE
Middle Name:
Last Name:TADIESSE DOMGUIA
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 1:1428 S 88TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4303
Mailing Address - Country:US
Mailing Address - Phone:414-379-1079
Mailing Address - Fax:
Practice Address - Street 1:1428 S 88TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4303
Practice Address - Country:US
Practice Address - Phone:414-379-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver