Provider Demographics
NPI:1629049432
Name:DOMINGUEZ, JORGE (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
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:URB. VALENCIA CALLE TOLEDO #608
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00923
Mailing Address - Country:US
Mailing Address - Phone:787-258-2835
Mailing Address - Fax:
Practice Address - Street 1:231 CALLE DUARTE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-3631
Practice Address - Country:US
Practice Address - Phone:787-773-3250
Practice Address - Fax:787-767-5918
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13324208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
20147Medicare ID - Type Unspecified
H81352Medicare UPIN