Provider Demographics
NPI:1588897359
Name:DOMINGUEZ, JOHN ANTHONY
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ANTHONY
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3746 FOOTHILL BLVD B140
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91214
Mailing Address - Country:US
Mailing Address - Phone:602-495-5797
Mailing Address - Fax:602-262-6201
Practice Address - Street 1:150 S. 12 STREET
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-2301
Practice Address - Country:US
Practice Address - Phone:602-495-5797
Practice Address - Fax:602-262-6201
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3887207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZI18437Medicare UPIN