Provider Demographics
NPI:1669789814
Name:DOMINGUEZ, JESSE VINCENT (OD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:VINCENT
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:OD
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 634
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0634
Mailing Address - Country:US
Mailing Address - Phone:928-627-4525
Mailing Address - Fax:928-627-4524
Practice Address - Street 1:725 E. MAIN ST.
Practice Address - Street 2:SUITE 1C
Practice Address - City:SOMERTON
Practice Address - State:AZ
Practice Address - Zip Code:85350-0634
Practice Address - Country:US
Practice Address - Phone:928-627-4525
Practice Address - Fax:928-627-4524
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1210152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ144738Medicare PIN