Healthcare Provider Details

I. General information

NPI: 1104840073
Provider Name (Legal Business Name): RAFAEL ROBERTO DOMINGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W SUPERIOR ST
CHICAGO IL
60622-5646
US

IV. Provider business mailing address

1321 W HOOD AVE # 2
CHICAGO IL
60660-2507
US

V. Phone/Fax

Practice location:
  • Phone: 312-666-3494
  • Fax:
Mailing address:
  • Phone: 773-856-5308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-112018
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036112018
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: