Provider Demographics
NPI:1073571824
Name:DOMINGUE, C M (MD)
Entity type:Individual
Prefix:
First Name:C
Middle Name:M
Last Name:DOMINGUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 ROSS ST
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:LA
Mailing Address - Zip Code:71263-9798
Mailing Address - Country:US
Mailing Address - Phone:318-428-3237
Mailing Address - Fax:318-428-6180
Practice Address - Street 1:706 ROSS ST
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263-9798
Practice Address - Country:US
Practice Address - Phone:318-428-3237
Practice Address - Fax:318-428-7896
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1494208Medicaid
LAG54221Medicare UPIN
LA1494208Medicaid