Provider Demographics
NPI:1679775068
Name:DOMOND, JACQUES REGINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUES
Middle Name:REGINE
Last Name:DOMOND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CARMAN AVE
Mailing Address - Street 2:APT H-6
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554
Mailing Address - Country:US
Mailing Address - Phone:516-495-4778
Mailing Address - Fax:
Practice Address - Street 1:8900 VAN WYCK EXPY
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2832
Practice Address - Country:US
Practice Address - Phone:718-206-6070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248489208000000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400000785Medicare PIN