Provider Demographics
NPI:1205893591
Name:DOMBROWSKI, JACQUELINE A (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:DOMBROWSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3560 NORTH BUFFALO ROAD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1934
Mailing Address - Country:US
Mailing Address - Phone:716-662-8510
Mailing Address - Fax:716-662-8574
Practice Address - Street 1:3560 NORTH BUFFALO
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1934
Practice Address - Country:US
Practice Address - Phone:716-662-8510
Practice Address - Fax:716-662-8574
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219856207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02173233Medicaid
NYDD1198Medicare ID - Type Unspecified
NY02173233Medicaid