Provider Demographics
NPI:1295398725
Name:DOMINGUEZ, MICHELLE FRANCES (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:FRANCES
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87-89 NICHOLS ST APT 4
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-6611
Mailing Address - Country:US
Mailing Address - Phone:201-707-7984
Mailing Address - Fax:
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2545
Practice Address - Country:US
Practice Address - Phone:718-960-6202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-19
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11444500208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty