Provider Demographics
NPI:1467400697
Name:DOMINGUEZ, EDWARD PAUL (M D)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:PAUL
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 MARBLEVISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-9012
Mailing Address - Country:US
Mailing Address - Phone:614-261-1900
Mailing Address - Fax:614-261-7538
Practice Address - Street 1:3545 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 525
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3907
Practice Address - Country:US
Practice Address - Phone:614-261-1900
Practice Address - Fax:614-261-7538
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2308208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2664620Medicaid
4184711Medicare PIN
OH2664620Medicaid