Basic Information
| Provider Information | |||||||||
| NPI: | 1871796086 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DENNIS O. DOMINGUEZ, MD, A MEDICAL CORPORATION | ||||||||
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| OtherOrganizationName: | DENNIS O. DOMINGUEZ, MD, A MEDICAL CORPORATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 N. MOLLISON AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194413550 | ||||||||
| FaxNumber: | 6195792921 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 N. MOLLISON AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194413550 | ||||||||
| FaxNumber: | 6195792921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 05/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | VAZQUEZ | ||||||||
| AuthorizedOfficialFirstName: | JUANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6194413550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G43179 | 05 | CA | MEDICAID |