Provider Demographics
NPI:1992867766
Name:DOMINGUEZ, EMIL R JR (MD)
Entity Type:Individual
Prefix:MR
First Name:EMIL
Middle Name:R
Last Name:DOMINGUEZ
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:409 E MERCED AVE
Mailing Address - Street 2:SUITE #A
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-5061
Mailing Address - Country:US
Mailing Address - Phone:626-931-0901
Mailing Address - Fax:626-931-0905
Practice Address - Street 1:409 E MERCED AVE
Practice Address - Street 2:SUITE #A
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-5061
Practice Address - Country:US
Practice Address - Phone:626-931-0901
Practice Address - Fax:626-931-0905
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA43966208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A439660Medicaid