Provider Demographics
NPI:1285742312
Name:DOMINIC, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DOMINIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:7780 N FRESNO ST
Mailing Address - Street 2:STE. 100
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2413
Mailing Address - Country:US
Mailing Address - Phone:559-493-5760
Mailing Address - Fax:559-493-5292
Practice Address - Street 1:7780 N FRESNO ST
Practice Address - Street 2:STE. 100
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2413
Practice Address - Country:US
Practice Address - Phone:559-493-5760
Practice Address - Fax:559-493-5292
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2015-05-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG68190207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G681900Medicaid
CAF36273Medicare UPIN
CA00G681900Medicaid