Provider Demographics
NPI:1336255694
Name:MACARIO L. DOMAGUING JR M.D. INC
Entity Type:Organization
Organization Name:MACARIO L. DOMAGUING JR M.D. INC
Other - Org Name:M.L.DOMAGUING,JR.M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MACARIO
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOMAGUING JR.
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:626-335-4129
Mailing Address - Street 1:648 RANCHO LOS NOGALES DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3351
Mailing Address - Country:US
Mailing Address - Phone:626-862-3584
Mailing Address - Fax:626-331-1839
Practice Address - Street 1:648 RANCHO LOS NOGALES DR
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3351
Practice Address - Country:US
Practice Address - Phone:626-862-3584
Practice Address - Fax:626-331-1839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW22352Medicaid
CAW22352Medicare PIN