Provider Demographics
NPI:1871796086
Name:DENNIS O. DOMINGUEZ, MD, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:DENNIS O. DOMINGUEZ, MD, A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JUANA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-441-3550
Mailing Address - Street 1:505 N. MOLLISON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021
Mailing Address - Country:US
Mailing Address - Phone:619-441-3550
Mailing Address - Fax:619-579-2921
Practice Address - Street 1:505 N. MOLLISON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021
Practice Address - Country:US
Practice Address - Phone:619-441-3550
Practice Address - Fax:619-579-2921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G43179Medicaid
CA00G43179Medicaid