Provider Demographics
NPI:1316729510
Name:DOMINGUEZ, ESMERALDA
Entity type:Individual
Prefix:
First Name:ESMERALDA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 CALLE BUEN CONSEJO
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-1619
Mailing Address - Country:US
Mailing Address - Phone:938-246-9406
Mailing Address - Fax:
Practice Address - Street 1:213 CALLE BUEN CONSEJO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-1619
Practice Address - Country:US
Practice Address - Phone:938-246-9406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0080033562377Medicaid