Basic Information
| Provider Information | |||||||||
| NPI: | 1053396127 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINGO | ||||||||
| FirstName: | MARY ANN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6901 N MAIN ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | GRANGER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465308022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746474500 | ||||||||
| FaxNumber: | 5746476354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | 01061323A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 000000803598 | 01 | IN | BCBS MAIN STREET | OTHER | 200537970 | 05 | IN | MEDICAID |