Provider Demographics
NPI:1932966678
Name:MARES, DOMINIQUE ANTHONY (CSFA)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:ANTHONY
Last Name:MARES
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E CEVALLOS APT 175
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78204-1981
Mailing Address - Country:US
Mailing Address - Phone:956-265-7100
Mailing Address - Fax:
Practice Address - Street 1:600 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2235
Practice Address - Country:US
Practice Address - Phone:361-881-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX191825246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant