Provider Demographics
NPI:1609119353
Name:DOMINGUEZ, MATTHEW LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LEE
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7033 EAST TUDOR CENTRE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:95507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4175 TUDOR CENTRE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5917
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03613907762084P0800X
390200000X
AK1931032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA