Provider Demographics
NPI:1538146139
Name:DOMINGUEZ PASCUAL, MILDALIAS (MD)
Entity Type:Individual
Prefix:MRS
First Name:MILDALIAS
Middle Name:
Last Name:DOMINGUEZ PASCUAL
Suffix:
Gender:F
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:PO BOX 4317
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00694-4317
Mailing Address - Country:US
Mailing Address - Phone:787-810-1322
Mailing Address - Fax:787-883-0222
Practice Address - Street 1:PARQUE INDUSTRIAL DCH KM 48.6
Practice Address - Street 2:
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-884-6564
Practice Address - Fax:787-854-0352
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9886208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE82754Medicare UPIN
PR82158Medicare UPIN