Healthcare Provider Details

I. General information

NPI: 1750615878
Provider Name (Legal Business Name): MR. DOMINGO S. JARQUIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 MISSION RD
SOUTH SAN FRANCISCO CA
94080-1302
US

IV. Provider business mailing address

1620 N CARPENTER RD
MODESTO CA
95351-1153
US

V. Phone/Fax

Practice location:
  • Phone: 650-243-4850
  • Fax:
Mailing address:
  • Phone: 209-577-1903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1952493199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: