Basic Information
| Provider Information | |||||||||
| NPI: | 1437218534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | ROLAND | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2829 BABCOCK | ||||||||
| Address2: | SUITE 407 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782296012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106145437 | ||||||||
| FaxNumber: | 2109495051 | ||||||||
| Practice Location | |||||||||
| Address1: | 2829 BABCOCK | ||||||||
| Address2: | SUITE 407 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782296012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106145437 | ||||||||
| FaxNumber: | 2109495051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 05/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | H3874 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 124696909 | 01 | TX | CSHCN | OTHER | 124696908 | 05 | TX | MEDICAID | 124696905 | 05 | TX | MEDICAID |