Healthcare Provider Details

I. General information

NPI: 1376074195
Provider Name (Legal Business Name): JESUS DOMINGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-7911
  • Fax:
Mailing address:
  • Phone: 410-955-7911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD96407
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: