Basic Information
| Provider Information | |||||||||
| NPI: | 1467420927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ-BURNS | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SW 62 AVENUE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331553009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 SW 62ND AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331553009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME0090306 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 272287900 | 05 | FL | MEDICAID | 03375 | 01 | FL | BCBS | OTHER |