Provider Demographics
NPI:1598768749
Name:DOMINIQUE, COLETTE (MD)
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:
Last Name:DOMINIQUE
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:4429 CLARA ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-6902
Practice Address - Country:US
Practice Address - Phone:504-842-9885
Practice Address - Fax:504-842-9836
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9182207V00000X
LA303382207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AJ839OtherBLUE CROSS BLUE SHIELD
TX168588501Medicaid
TXI17310Medicare UPIN