Provider Demographics
NPI:1235170556
Name:DOMINGUEZ, MIGUEL A (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
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 1:18102 IRVINE BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3402
Mailing Address - Country:US
Mailing Address - Phone:714-371-9000
Mailing Address - Fax:714-730-2720
Practice Address - Street 1:18102 IRVINE BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3402
Practice Address - Country:US
Practice Address - Phone:714-371-9000
Practice Address - Fax:714-730-2720
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64086207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG64086AMedicare ID - Type Unspecified
CAE85038Medicare UPIN