Provider Demographics
NPI:1013216704
Name:DOMINGUEZ, MARIA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 PORTLAND AVE
Mailing Address - Street 2:EMERGENCY
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3001
Mailing Address - Country:US
Mailing Address - Phone:585-922-4000
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:EMERGENCY
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3001
Practice Address - Country:US
Practice Address - Phone:585-922-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260757207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03347537Medicaid
NYJ400277834-GRPBA0017Medicare PIN
NYJ400278177-GRP70008AMedicare PIN