Provider Demographics
NPI:1013051135
Name:CORDERO, DOMINGO B (MD)
Entity type:Individual
Prefix:DR
First Name:DOMINGO
Middle Name:B
Last Name:CORDERO
Suffix:
Gender:M
Credentials:MD
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 51519
Mailing Address - Street 2:
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00950-1519
Mailing Address - Country:US
Mailing Address - Phone:787-722-5006
Mailing Address - Fax:787-725-7490
Practice Address - Street 1:29 CALLE WASHINGTON
Practice Address - Street 2:ASHFORD MEDICAL CENTER SUITE 310
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-1510
Practice Address - Country:US
Practice Address - Phone:787-722-5006
Practice Address - Fax:787-725-7490
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4175103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical