Provider Demographics
NPI:1699154294
Name:DOMINO, MARIA PAULA (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:PAULA
Last Name:DOMINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:
Other - Last Name:DOMINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:504 CLINTON CENTER DR STE 4300
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5610
Mailing Address - Country:US
Mailing Address - Phone:601-984-5185
Mailing Address - Fax:601-984-5190
Practice Address - Street 1:1410 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5185
Practice Address - Fax:601-815-5660
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS28767208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology