Provider Demographics
NPI:1467534313
Name:DOMINGUEZ, JESSE SERRANO (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:SERRANO
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6044 CHURCHILL STREET
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407
Mailing Address - Country:US
Mailing Address - Phone:831-261-6596
Mailing Address - Fax:
Practice Address - Street 1:6604 CHURCHILL ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-2069
Practice Address - Country:US
Practice Address - Phone:831-261-6596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8942207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine