Provider Demographics
NPI:1437205671
Name:DOMINGUEZ, MANUEL GARCIA JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:GARCIA
Last Name:DOMINGUEZ
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1431 N WESTERN AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-7712
Mailing Address - Country:US
Mailing Address - Phone:773-661-1285
Mailing Address - Fax:773-904-8129
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:773-770-3409
Practice Address - Fax:773-770-3418
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2018-07-24
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Provider Licenses
StateLicense IDTaxonomies
IL036087595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087595Medicaid
IL01634263OtherBLUE CROSS BLUE SHIELD
ILF04052Medicare UPIN
IL036087595Medicaid