MEDICARE: IVAN DOMINGUEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	D5281191	CA

General Provider Information

NPI Number	:	1629814116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVAN DOMINGUEZ

Provider Business Mailing Address
First Line	:	824 MOUNT RANIER WAY
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-4449
Country	:	US
Telephone Number	:	818-519-3699
Fax Number	:

Provider Business Practice Location Address
First Line	:	824 MOUNT RANIER WAY
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-4449
Country	:	US
Telephone Number	:	818-519-3699
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2024
Last Update Date	:	07/12/2024

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Directions to “ IVAN DOMINGUEZ ” Practice Location

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