Provider Demographics
NPI:1184711863
Name:DOMINGUEZ, VICTOR LUIS (MD)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:LUIS
Last Name:DOMINGUEZ
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 1:2585 W HOUGHTON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-9624
Mailing Address - Country:US
Mailing Address - Phone:989-366-2900
Mailing Address - Fax:
Practice Address - Street 1:2585 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9624
Practice Address - Country:US
Practice Address - Phone:989-366-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI069548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE 80052Medicare UPIN