Provider Demographics
NPI:1962589010
Name:FELICIANO, DOMINGO (MD)
Entity type:Individual
Prefix:
First Name:DOMINGO
Middle Name:
Last Name:FELICIANO
Suffix:
Gender:M
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:PO BOX 366734
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34136-6734
Mailing Address - Country:US
Mailing Address - Phone:239-992-4344
Mailing Address - Fax:239-992-5042
Practice Address - Street 1:10459 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-5535
Practice Address - Country:US
Practice Address - Phone:239-992-4344
Practice Address - Fax:239-992-5042
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G08642Medicare UPIN
FL26742BMedicare PIN