Provider Demographics
NPI:1538208038
Name:DOMINGUEZ, JORGE E (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:E
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-3214
Mailing Address - Country:US
Mailing Address - Phone:956-548-1100
Mailing Address - Fax:956-504-1907
Practice Address - Street 1:3150 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-3214
Practice Address - Country:US
Practice Address - Phone:956-548-1100
Practice Address - Fax:956-504-1907
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3561208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136415009Medicaid
TXE02293Medicare UPIN
TX80X030Medicare ID - Type Unspecified