Healthcare Provider Details

I. General information

NPI: 1295398725
Provider Name (Legal Business Name): MICHELLE FRANCES DOMINGUEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 3RD AVE
BRONX NY
10457-2545
US

IV. Provider business mailing address

87-89 NICHOLS ST APT 4
NEWARK NJ
07105-6611
US

V. Phone/Fax

Practice location:
  • Phone: 718-960-6202
  • Fax:
Mailing address:
  • Phone: 201-707-7984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA11444500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25MA11444500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: