MEDICARE: DR. JUAN C DOMINGUEZ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	118268	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	403973	OTHER	KS	BLUE CROSS/BLUE SHIELD KS
2	2180287	OTHER	MO	AETNA
3	25683028	OTHER	MO	BLUE CROSS/BLUE SHIELD KC
4	26D0896653	OTHER	MO	CLIA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	10001381300	OTHER	MO	COMMUNITY HEALTH PLAN
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023036001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUAN C DOMINGUEZ MD

Provider Business Mailing Address
First Line	:	5210 NORTH BELT HWY
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-1211
Country	:	US
Telephone Number	:	816-271-4995
Fax Number	:	816-271-4915

Provider Business Practice Location Address
First Line	:	5210 NORTH BELT HWY
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-1211
Country	:	US
Telephone Number	:	816-271-4995
Fax Number	:	816-271-4915

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	11/20/2017

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Directions to “ DR. JUAN C DOMINGUEZ MD” Practice Location

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