Basic Information
| Provider Information | |||||||||
| NPI: | 1497730097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OFFIONG | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5841 | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785025841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9569264334 | ||||||||
| FaxNumber: | 9569264350 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859225067 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01058488A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | M0845 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 234371 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 234371 | NY | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 00W044 | 01 | TX | MEDICARE GROUP | OTHER | 00X144 | 01 | TX | MEDICARE GROUP | OTHER | 178763201 | 05 | TX | MEDICAID | 8J8794 | 01 | TX | MEDICARE PTAN | OTHER | 0067ND | 01 | TX | BCTX GROUP | OTHER | 1134298466 | 01 | TX | GROUP NPI | OTHER | 1356361976 | 01 | TX | GROUP NPI | OTHER |