Provider Demographics
NPI:1407599103
Name:DOMINGUEZ, MAR (MD)
Entity Type:Individual
Prefix:
First Name:MAR
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 1:994 CHESTNUT RIDGE RD APT 305
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3294
Mailing Address - Country:US
Mailing Address - Phone:561-777-5116
Mailing Address - Fax:
Practice Address - Street 1:3811 OHARA ST STE 431
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2561
Practice Address - Country:US
Practice Address - Phone:412-246-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program