Provider Demographics
NPI:1891052361
Name:DOMINGO, JAY
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92-530 PALAILAI ST
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-1038
Mailing Address - Country:US
Mailing Address - Phone:808-221-8287
Mailing Address - Fax:
Practice Address - Street 1:92-530 PALAILAI ST
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-1038
Practice Address - Country:US
Practice Address - Phone:808-221-8287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman