Provider Demographics
NPI:1962801142
Name:DOMINGO, EILEEN JOY
Entity type:Individual
Prefix:
First Name:EILEEN JOY
Middle Name:
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EILEEN JOY
Other - Middle Name:
Other - Last Name:DELA CRUZ DOMINGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35105 ENCHANTED PKWY S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8379
Mailing Address - Country:US
Mailing Address - Phone:833-411-5469
Mailing Address - Fax:855-459-3020
Practice Address - Street 1:35105 ENCHANTED PKWY S STE G101
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8379
Practice Address - Country:US
Practice Address - Phone:833-411-5469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL60561517207Q00000X
WAOP60765124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine