Provider Demographics
NPI:1093746364
Name:CAMACHO, MIGUEL DOMINGUEZ (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:DOMINGUEZ
Last Name:CAMACHO
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 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:4581 10TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:GUADALUPE
Practice Address - State:CA
Practice Address - Zip Code:93434-1454
Practice Address - Country:US
Practice Address - Phone:805-343-5577
Practice Address - Fax:805-343-5578
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP70986FOtherFAMILY PACK
CACJ5474OtherMEDICARE RAILROAD GROUP PTAN #
CAP00725474OtherMEDICARE RAILROAD GROUP MEMBER PTAN#
CA00A535410Medicaid
CAFHC70986FMedicaid
CA551973Medicare Oscar/Certification
CAW1508BMedicare PIN
CAG13011Medicare UPIN
CAAS193YMedicare PIN
CAAS193ZMedicare PIN
CAW1508Medicare PIN
CACJ5474OtherMEDICARE RAILROAD GROUP PTAN #
CA00A535410Medicaid