Healthcare Provider Details

I. General information

NPI: 1245856111
Provider Name (Legal Business Name): SARAH DOMINGUEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 ROUTE 70 STE 101
LAKEWOOD NJ
08701-5897
US

IV. Provider business mailing address

475 ROUTE 70 STE 101
LAKEWOOD NJ
08701-5897
US

V. Phone/Fax

Practice location:
  • Phone: 732-364-8000
  • Fax: 732-364-4601
Mailing address:
  • Phone: 732-364-8000
  • Fax: 732-364-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMT221576
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA12319600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: