Provider Demographics
NPI:1366451122
Name:DOMINGUEZ, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
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 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:803-648-0587
Mailing Address - Fax:806-648-9846
Practice Address - Street 1:1021 SILVER BLUFF RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803
Practice Address - Country:US
Practice Address - Phone:806-648-0587
Practice Address - Fax:803-648-9846
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1246241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E56699Medicare UPIN
TXB149017Medicare PIN
TXB149017Medicare PIN
TXP01093322OtherRAILROAD MEDICARE