Provider Demographics
NPI:1609056795
Name:M DOMINGUEZ JR MD SC
Entity Type:Organization
Organization Name:M DOMINGUEZ JR MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:GARCIA
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:773-770-3409
Mailing Address - Street 1:1431 N WESTERN AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:773-770-3409
Mailing Address - Fax:773-770-3418
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:773-770-3409
Practice Address - Fax:773-770-3418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208970Medicare PIN