Provider Demographics
NPI:1932143369
Name:DOMINGUEZ, LOURDES M (MD)
Entity Type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:M
Last Name:DOMINGUEZ
Suffix:
Gender:F
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:DEPT OF PSYCHIATRY, TRUSTEES OF COLUMBIA UNIVERSITY
Mailing Address - Street 2:622 WEST 168TH STREET, BOX 260
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:212-305-2330
Mailing Address - Fax:212-305-4724
Practice Address - Street 1:ALLEN PAVILION 3 RIVER EAST
Practice Address - Street 2:5141 BROADWAY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034
Practice Address - Country:US
Practice Address - Phone:212-932-4165
Practice Address - Fax:212-932-5369
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1718392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01589844Medicaid
NY59F281Medicare ID - Type Unspecified
NYE48962Medicare UPIN