1972728046 NPI number — DR. REBECCA CONRAD DOMINGUEZ MD

Table of content: DR. REBECCA CONRAD DOMINGUEZ MD (NPI 1972728046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972728046 NPI number — DR. REBECCA CONRAD DOMINGUEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMINGUEZ
Provider First Name:
REBECCA
Provider Middle Name:
CONRAD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONRAD
Provider Other First Name:
REBECCA
Provider Other Middle Name:
THERESE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972728046
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6730
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85246-6730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-821-3600
Provider Business Mailing Address Fax Number:
480-821-3610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5656 S POWER RD
Provider Second Line Business Practice Location Address:
SUITE 137
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85295-8487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-821-3616
Provider Business Practice Location Address Fax Number:
480-857-2667
Provider Enumeration Date:
04/16/2007

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: 207V00000X , with the licence number:  130955 , 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: 9010088 . This is a "ABOG BOARD CERTFITIED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 231384 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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