Provider Demographics
NPI:1699872135
Name:JAVIER, DOMINGO GONZALES (MD)
Entity type:Individual
Prefix:MR
First Name:DOMINGO
Middle Name:GONZALES
Last Name:JAVIER
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 1:1701 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-1701
Mailing Address - Country:US
Mailing Address - Phone:304-325-5755
Mailing Address - Fax:304-323-1639
Practice Address - Street 1:1701 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-1701
Practice Address - Country:US
Practice Address - Phone:304-325-5755
Practice Address - Fax:304-323-1639
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10588208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1022384OtherWORKERS COMP
851945OtherMAMSI
VA062480OtherBC ANTHEM
103541OtherBLACK LUNG
VA7350431OtherVA MED ASSIS
0472131OtherUMWA FUNDS
V000267OtherCHAMPUS
WV0127512000Medicaid
4454937OtherAETNA
VA7350431OtherVA MED ASSIS
VA062480OtherBC ANTHEM