Provider Demographics
NPI:1114917424
Name:DOMINGUEZ, LEONARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONARDO
Middle Name:
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 5865
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-5865
Mailing Address - Country:US
Mailing Address - Phone:806-743-2898
Mailing Address - Fax:806-743-2787
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:2A100
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-2020
Practice Address - Fax:806-743-1782
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44328207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100846300AMedicaid
NM71180036Medicaid
NM79540OtherPRESBYTERIAN COMMERCIAL
TX131456101Medicaid
TX131456100OtherFIRSTCARE COMMERCIAL
TX154559202Medicaid
TX154559201Medicaid
TX8G7980OtherBC/BS
NMB017OtherTRIWEST
NM79540Medicaid
TX86979ZOtherHMO BLUE
NM79540Medicaid
TX154559202Medicaid
TX131456101Medicaid