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General NPI Number Information
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NPI Number | 1588897359
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Entity Type | Individual
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Provider Name | MR. JOHN ANTHONY DOMINGUEZ
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Gender | Male
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Dates
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Enumeration Date | 08/27/2009
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Last Update Date | 05/15/2024
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Provider Practice Location Address
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Address Line | 150 S. 12 STREET
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City | PHOENIX
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State | AZ
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Zip | 85034-2301
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Country | US
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Telephone | 602-495-5797
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Fax | 602-262-6201
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Provider Business Mailing Address
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Address Line | 3746 FOOTHILL BLVD B140
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City | GLENDALE
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State | CA
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Zip | 91214
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Country | US
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Telephone | 602-495-5797
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Fax | 602-262-6201
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 3887
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License Number State | AZ
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