Provider Demographics
NPI:1295835775
Name:DOMINGUEZ, JOSE LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
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 1:4517 LAVISTA RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4208
Mailing Address - Country:US
Mailing Address - Phone:770-723-1226
Mailing Address - Fax:
Practice Address - Street 1:2121 FOUNTAIN DR STE A
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2900
Practice Address - Country:US
Practice Address - Phone:770-736-3008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA36190207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine