Provider Demographics
NPI:1598765828
Name:DOMINGUEZ, EDWARD A (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1411 N BECKLEY AVE
Mailing Address - Street 2:PAV III STE#268
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1259
Mailing Address - Country:US
Mailing Address - Phone:214-947-4400
Mailing Address - Fax:214-947-4404
Practice Address - Street 1:1411 N BECKLEY AVE
Practice Address - Street 2:PAV III STE#268
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1259
Practice Address - Country:US
Practice Address - Phone:214-947-4400
Practice Address - Fax:214-947-4404
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1951207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147373806Medicaid
F40838Medicare UPIN
TX8K9854Medicare PIN