Provider Demographics
NPI:1023036001
Name:DOMINGUEZ, JUAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:C
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5210 NORTH BELT HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-1211
Mailing Address - Country:US
Mailing Address - Phone:816-271-4995
Mailing Address - Fax:816-271-4915
Practice Address - Street 1:5210 NORTH BELT HWY
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-1211
Practice Address - Country:US
Practice Address - Phone:816-271-4995
Practice Address - Fax:816-271-4915
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO118268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS403973OtherBLUE CROSS/BLUE SHIELD KS
MO2180287OtherAETNA
MO25683028OtherBLUE CROSS/BLUE SHIELD KC
MO26D0896653OtherCLIA
MO246807846Medicaid
MO10001381300OtherCOMMUNITY HEALTH PLAN
KS100381150AMedicaid
MO10001381300OtherCOMMUNITY HEALTH PLAN
MS080152192Medicare ID - Type UnspecifiedRAILROAD
MO246807846Medicaid