Provider Demographics
NPI:1619965472
Name:DOMINGUEZ, ROBERT JAVIER (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAVIER
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 1:784 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3983
Mailing Address - Country:US
Mailing Address - Phone:740-687-0100
Mailing Address - Fax:740-687-0145
Practice Address - Street 1:784 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3983
Practice Address - Country:US
Practice Address - Phone:740-687-0100
Practice Address - Fax:740-687-0145
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053076D207P00000X, 207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0613161Medicaid
OH35053076DOtherOHIO MEDICAL LICENSE
OH0613161Medicaid
OHDO7143951Medicare PIN
0629145Medicare UPIN
OH$$$$$$$$$-00OtherBWC