Basic Information
| Provider Information | |||||||||
| NPI: | 1104840073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | RAFAEL | ||||||||
| MiddleName: | ROBERTO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1321 W HOOD AVE # 2 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606602507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738565308 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 W SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606225646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126663494 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036-112018 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 036112018 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.