Provider Demographics
NPI:1629286646
Name:DOMANGUE, CHAD M (MD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:M
Last Name:DOMANGUE
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 1:76 STARBRUSH CIR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7208
Mailing Address - Country:US
Mailing Address - Phone:985-801-0581
Mailing Address - Fax:
Practice Address - Street 1:76 STARBRUSH CIR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7208
Practice Address - Country:US
Practice Address - Phone:985-801-0581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202018208VP0014X
KYTP-3662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology