Provider Demographics
NPI:1043428170
Name:DOMINGUEZ, MARK JASON (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JASON
Last Name:DOMINGUEZ
Suffix:
Gender:M
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:PO BOX 54482
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70154-4482
Mailing Address - Country:US
Mailing Address - Phone:985-898-3740
Mailing Address - Fax:985-898-3739
Practice Address - Street 1:606 W 11TH AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-3630
Practice Address - Country:US
Practice Address - Phone:985-892-3766
Practice Address - Fax:985-893-9567
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200251208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery