Basic Information
| Provider Information | |||||||||
| NPI: | 1083080535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2150 PENNSYLVANIA AVE NW | ||||||||
| Address2: | GW MFA DEPARTMENT OF EMERGENCY MEDICINE | ||||||||
| City: | WASHINGTON DC | ||||||||
| State: | DC | ||||||||
| PostalCode: | 20037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027980100 | ||||||||
| FaxNumber: | 2023793570 | ||||||||
| Practice Location | |||||||||
| Address1: | 2150 PENNSYLVANIA AVE | ||||||||
| Address2: | GW MEDICAL FACULTY ASSOCIATES, DEPT OF EMERG. MED. | ||||||||
| City: | WASHINGTON DC | ||||||||
| State: | DC | ||||||||
| PostalCode: | 20037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027980100 | ||||||||
| FaxNumber: | 2023793570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2015 | ||||||||
| LastUpdateDate: | 12/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD046182 | DC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | D0085304 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD046182 | 01 | DC | LICENSE NUMBER | OTHER |