Provider Demographics
NPI:1487803490
Name:DOMINGUEZ, JENNIFER (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:ESTRELLA
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 63362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3362
Mailing Address - Country:US
Mailing Address - Phone:919-684-8111
Mailing Address - Fax:
Practice Address - Street 1:2100 ERWIN RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3941
Practice Address - Country:US
Practice Address - Phone:919-684-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC201201649207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program