Provider Demographics
NPI:1366698235
Name:ONOFRE, DOMINIC SIMON (LPT)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:SIMON
Last Name:ONOFRE
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5904 S COOPER ST STE 104107
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-4494
Mailing Address - Country:US
Mailing Address - Phone:682-238-3243
Mailing Address - Fax:817-549-0106
Practice Address - Street 1:2340 W I 20 STE 218
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-7603
Practice Address - Country:US
Practice Address - Phone:682-238-3243
Practice Address - Fax:817-549-0106
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1182747225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165348701Medicaid
456643Medicare Oscar/Certification
456643Medicare PIN