Provider Demographics
NPI:1629146873
Name:JORGE E. DOMINGUEZ MD PA
Entity Type:Organization
Organization Name:JORGE E. DOMINGUEZ MD PA
Other - Org Name:BROWNSVILLE PEDIATRIC & ADOLESCENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-548-1100
Mailing Address - Street 1:3150 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-3214
Mailing Address - Country:US
Mailing Address - Phone:956-548-1100
Mailing Address - Fax:956-504-1907
Practice Address - Street 1:3150 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-3214
Practice Address - Country:US
Practice Address - Phone:956-548-1100
Practice Address - Fax:956-504-1907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1538208038Medicaid
TX084901001Medicaid
TX08490101.02Medicaid
TX091753602Medicaid