Provider Demographics
NPI:1679521975
Name:DOMINGO, GLORIA SUJA (MD)
Entity type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:SUJA
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 N HAMMONDS FERRY RD STE C
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM
Mailing Address - State:MD
Mailing Address - Zip Code:21090
Mailing Address - Country:US
Mailing Address - Phone:410-789-2500
Mailing Address - Fax:410-789-2501
Practice Address - Street 1:809 N HAMMONDS FERRY RD STE C
Practice Address - Street 2:
Practice Address - City:LINTHICUM
Practice Address - State:MD
Practice Address - Zip Code:21090
Practice Address - Country:US
Practice Address - Phone:410-789-2500
Practice Address - Fax:410-789-2501
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD26491208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD270871001Medicaid