Provider Demographics
NPI:1699322867
Name:RDM PROFESSIONAL SERVICES, INC.
Entity type:Organization
Organization Name:RDM PROFESSIONAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROLANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ MUSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-610-6389
Mailing Address - Street 1:437 SW ROSEMARY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-6715
Mailing Address - Country:US
Mailing Address - Phone:973-610-6389
Mailing Address - Fax:386-935-4331
Practice Address - Street 1:437 SW ROSEMARY DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024-6715
Practice Address - Country:US
Practice Address - Phone:973-610-6389
Practice Address - Fax:386-935-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015321200Medicaid