Provider Demographics
NPI:1679846430
Name:ROLAND J. DOMINGUEZ M.D., P.A.
Entity Type:Organization
Organization Name:ROLAND J. DOMINGUEZ M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-492-2900
Mailing Address - Street 1:2829 BABCOCK RD
Mailing Address - Street 2:SUITE #407
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-6028
Mailing Address - Country:US
Mailing Address - Phone:210-614-5437
Mailing Address - Fax:210-949-5051
Practice Address - Street 1:2829 BABCOCK RD
Practice Address - Street 2:SUITE #407
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6028
Practice Address - Country:US
Practice Address - Phone:210-614-5437
Practice Address - Fax:210-949-5051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3874261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124696905Medicaid