Provider Demographics
NPI:1508971771
Name:COLETTE M DOMINIQUE MD PA
Entity Type:Organization
Organization Name:COLETTE M DOMINIQUE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COLETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:972-256-3700
Mailing Address - Street 1:3501 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-3636
Mailing Address - Country:US
Mailing Address - Phone:972-256-3700
Mailing Address - Fax:972-258-9887
Practice Address - Street 1:3501 N MACARTHUR BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-3636
Practice Address - Country:US
Practice Address - Phone:972-256-3700
Practice Address - Fax:972-258-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9182207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0024QSOtherBLUE CROSS BLUE SHIELD
TXI17310Medicare UPIN
00332XMedicare PIN