Individual
MARIO L DOMINGUEZ
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1690 MAIN ST, SUITE 4, SOUTH WEYMOUTH, MA 02190-1279
(781) 337-8688
(781) 337-8754
Mailing address
1690 MAIN ST, SUITE 4, SOUTH WEYMOUTH, MA 02190-1279
(781) 337-8688
(781) 337-8754
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
151294
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
151274
TAHP
MA
05
—
3153517
—
MA
01
—
71156
HPHC
MA
01
—
BX6466
MEDICARE PTAN #
MA
01
—
J17080
BC/BS
MA
Enumeration date
07/06/2006
Last updated
08/04/2011
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