Provider Demographics
NPI:1982195939
Name:DOMINGUEZ, EDUARDO JOSE (SA-C)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:JOSE
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221135
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20153-1135
Mailing Address - Country:US
Mailing Address - Phone:703-349-1379
Mailing Address - Fax:
Practice Address - Street 1:12011 LEE JACKSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033
Practice Address - Country:US
Practice Address - Phone:703-349-1379
Practice Address - Fax:214-764-0880
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12-135246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant