1225063811 NPI number — DR. DENNIS OLIVER DOMINGUEZ M.D.

Table of content: DR. DENNIS OLIVER DOMINGUEZ M.D. (NPI 1225063811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225063811 NPI number — DR. DENNIS OLIVER DOMINGUEZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMINGUEZ
Provider First Name:
DENNIS
Provider Middle Name:
OLIVER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225063811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 N MOLLISON AVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
EL CAJON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92021-6159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-441-3550
Provider Business Mailing Address Fax Number:
619-579-2921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 N MOLLISON AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92021-6159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-441-3550
Provider Business Practice Location Address Fax Number:
619-579-2921
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G43179 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G43190 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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