Provider Demographics
NPI:1104898733
Name:CHARDON, DOMINGO (MD)
Entity type:Individual
Prefix:
First Name:DOMINGO
Middle Name:
Last Name:CHARDON
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:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:MERCEDITA
Mailing Address - State:PR
Mailing Address - Zip Code:00715-0518
Mailing Address - Country:US
Mailing Address - Phone:787-844-0705
Mailing Address - Fax:787-844-0706
Practice Address - Street 1:917 AVE TITO CASTRO
Practice Address - Street 2:SAINT LUKES MEMORIAL HOSPITAL
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00731-0000
Practice Address - Country:US
Practice Address - Phone:787-844-0705
Practice Address - Fax:787-844-0706
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9184174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRF58183Medicare UPIN
PR83340Medicare ID - Type Unspecified