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General NPI Number Information
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NPI Number | 1669789814
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Entity Type | Individual
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Provider Name | JESSE VINCENT DOMINGUEZ O.D.
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Gender | Male
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Dates
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Enumeration Date | 09/09/2010
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Last Update Date | 08/14/2013
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Provider Practice Location Address
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Address Line | 725 E. MAIN ST. SUITE 1C
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City | SOMERTON
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State | AZ
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Zip | 85350-0634
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Country | US
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Telephone | 928-627-4525
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Fax | 928-627-4524
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Provider Business Mailing Address
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Address Line | PO BOX 634
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City | SOMERTON
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State | AZ
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Zip | 85350-0634
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Country | US
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Telephone | 928-627-4525
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Fax | 928-627-4524
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1210
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License Number State | AZ
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