Provider Demographics
NPI:1962418178
Name:DOMINGUE, JEFFREY TODD (DPM)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:TODD
Last Name:DOMINGUE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:MR
Other - First Name:JEFFREY
Other - Middle Name:TODD
Other - Last Name:DOMINGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:1200 S 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-0900
Mailing Address - Country:US
Mailing Address - Phone:605-782-8305
Mailing Address - Fax:605-336-1677
Practice Address - Street 1:2100 S MARION RD
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-3646
Practice Address - Country:US
Practice Address - Phone:605-322-5180
Practice Address - Fax:605-322-1301
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO682213ES0103X
SD237213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U68075Medicare UPIN