Provider Demographics
NPI:1891738449
Name:DOMINGUEZ, MARIA G (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:G
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12050 VANCE JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1182
Mailing Address - Country:US
Mailing Address - Phone:210-699-8881
Mailing Address - Fax:210-699-0503
Practice Address - Street 1:12050 VANCE JACKSON RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-1182
Practice Address - Country:US
Practice Address - Phone:210-699-8881
Practice Address - Fax:210-699-0503
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF92952084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131203507Medicaid
TX131203507Medicaid
B21801Medicare UPIN