Provider Demographics
NPI:1134101918
Name:DOMINGUEZ, CARLOS E (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:E
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 1418
Mailing Address - Street 2:
Mailing Address - City:JUANA DIAZ
Mailing Address - State:PR
Mailing Address - Zip Code:00795-1418
Mailing Address - Country:US
Mailing Address - Phone:787-837-2923
Mailing Address - Fax:787-837-1688
Practice Address - Street 1:168A CALLE LAS FLORES
Practice Address - Street 2:
Practice Address - City:JUANA DIAZ
Practice Address - State:PR
Practice Address - Zip Code:00795-2532
Practice Address - Country:US
Practice Address - Phone:787-837-2923
Practice Address - Fax:787-837-1688
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5974208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR27686Medicare ID - Type UnspecifiedPROVIDER NUMBER
PRC79688Medicare UPIN