Provider Demographics
NPI:1770996050
Name:DOMINIQUE, OMAR L (MD)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:L
Last Name:DOMINIQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1760 E PECOS RD STE 431
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-3209
Mailing Address - Country:US
Mailing Address - Phone:480-237-3451
Mailing Address - Fax:480-499-5666
Practice Address - Street 1:1760 E PECOS RD STE 431
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-3209
Practice Address - Country:US
Practice Address - Phone:480-237-3451
Practice Address - Fax:480-499-5666
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ59823207Q00000X, 208M00000X
IAMD-46257207Q00000X, 208M00000X
MS926-L207Q00000X
IL036-144834208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine