Provider Demographics
NPI:1932372034
Name:L M DOMINGUEZ PC
Entity Type:Organization
Organization Name:L M DOMINGUEZ PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-596-8525
Mailing Address - Street 1:PO BOX 26904
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85068-6904
Mailing Address - Country:US
Mailing Address - Phone:480-596-8525
Mailing Address - Fax:480-596-8522
Practice Address - Street 1:8144 E CACTUS RD
Practice Address - Street 2:SUITE 800
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-5266
Practice Address - Country:US
Practice Address - Phone:480-596-8525
Practice Address - Fax:480-596-8522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16386174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ286866Medicaid
AW6904OtherHEALTHNET
AZ0766790OtherBCBS
D43107Medicare UPIN
AZ0766790OtherBCBS