Healthcare Provider Details

I. General information

NPI: 1063619310
Provider Name (Legal Business Name): MIGUEL DOMINGUEZ MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 01/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18102 IRVINE BLVD SUITE 208
TUSTIN CA
92780-3402
US

IV. Provider business mailing address

18102 IRVINE BLVD SUITE 208
TUSTIN CA
92780-3402
US

V. Phone/Fax

Practice location:
  • Phone: 714-371-9000
  • Fax: 714-730-2720
Mailing address:
  • Phone: 714-371-9000
  • Fax: 714-730-2720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG64086
License Number StateCA

VIII. Authorized Official

Name: CAROLYN HUBAY
Title or Position: OFFICE MANAGER
Credential:
Phone: 714-371-9000