MEDICARE: DR. MARIA C DOMINGUES O.D.

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	152W00000X	Optometrist	27OA00630100	NJ

General Provider Information

NPI Number	:	1174820682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIA C DOMINGUES O.D.

Provider Business Mailing Address
First Line	:	55 PAVONIA AVE
Second Line	:
City	:	KEARNY
State	:	NJ
Zip	:	07032-2230
Country	:	US
Telephone Number	:	954-734-0574
Fax Number	:

Provider Business Practice Location Address
First Line	:	1068 CLINTON AVE
Second Line	:
City	:	IRVINGTON
State	:	NJ
Zip	:	07111-3501
Country	:	US
Telephone Number	:	954-734-0574
Fax Number	:

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

Provider Enumeration Date	:	02/17/2011
Last Update Date	:	12/20/2021

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