Healthcare Provider Details

I. General information

NPI: 1386649358
Provider Name (Legal Business Name): PEDRO R DOMINGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W COLUMBIA ST STE 350
EVANSVILLE IN
47710-5610
US

IV. Provider business mailing address

350 W COLUMBIA ST STE 350
EVANSVILLE IN
47710-5610
US

V. Phone/Fax

Practice location:
  • Phone: 812-425-9999
  • Fax: 812-426-9981
Mailing address:
  • Phone: 812-425-9999
  • Fax: 812-426-9981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number01029742
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: