Basic Information
| Provider Information | |||||||||
| NPI: | 1972728046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | CONRAD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONRAD | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | THERESE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 6730 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852466730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808213600 | ||||||||
| FaxNumber: | 4808213610 | ||||||||
| Practice Location | |||||||||
| Address1: | 5656 S POWER RD | ||||||||
| Address2: | SUITE 137 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852958487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808213616 | ||||||||
| FaxNumber: | 4808572667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 03/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 130955 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | FC0259881 | 01 | AZ | DEA | OTHER | 9010088 | 01 | ABOG BOARD CERTFITIED | OTHER | 231384 | 05 | AZ | MEDICAID |