Provider Demographics
NPI:1063437507
Name:DOMINGUEZ, CHARLES E (OD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
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 1:21098 BAKE PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2163
Mailing Address - Country:US
Mailing Address - Phone:949-597-0104
Mailing Address - Fax:
Practice Address - Street 1:21098 BAKE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2163
Practice Address - Country:US
Practice Address - Phone:949-597-0104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 12292 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0610180005Medicare NSC
CAU96994Medicare UPIN
0610180002Medicare NSC
CAP01349077Medicare PIN
0610180003Medicare NSC
0610180004Medicare NSC
0610180001Medicare NSC
CAFA894PMedicare PIN