Provider Demographics
NPI:1609807874
Name:DOMINGUEZ, MARIO L (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:L
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 1:1690 MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1279
Mailing Address - Country:US
Mailing Address - Phone:781-337-8688
Mailing Address - Fax:781-337-8754
Practice Address - Street 1:1690 MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1279
Practice Address - Country:US
Practice Address - Phone:781-337-8688
Practice Address - Fax:781-337-8754
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA151294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA151274OtherTAHP
MABX6466OtherMEDICARE PTAN #
MAJ17080OtherBC/BS
MA3153517Medicaid
MA71156OtherHPHC
MABX6466OtherMEDICARE PTAN #
F44861Medicare UPIN