Provider Demographics
NPI:1568945004
Name:DOMINGUEZ, THOMAS JOSEPH IV
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:DOMINGUEZ
Suffix:IV
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-2870
Mailing Address - Country:US
Mailing Address - Phone:203-502-4723
Mailing Address - Fax:475-246-9952
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2870
Practice Address - Country:US
Practice Address - Phone:203-502-4723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4269363AS0400X, 207Q00000X, 207R00000X, 363A00000X, 363AM0700X, 363AS0400X
FLPA9113032363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLUR442OtherMEDICARE HF
FL105929600Medicaid