Basic Information
Provider Information | |||||||||
NPI: | 1114917424 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOMINGUEZ | ||||||||
FirstName: | LEONARDO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5865 | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794085865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067432898 | ||||||||
FaxNumber: | 8067432787 | ||||||||
Practice Location | |||||||||
Address1: | 3601 4TH ST | ||||||||
Address2: | 2A100 | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794300002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067432020 | ||||||||
FaxNumber: | 8067431782 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/27/2005 | ||||||||
LastUpdateDate: | 11/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 44328 | TX | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 100846300A | 05 | OK |   | MEDICAID | 71180036 | 05 | NM |   | MEDICAID | 79540 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | 131456101 | 05 | TX |   | MEDICAID | 131456100 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER | 154559202 | 05 | TX |   | MEDICAID | 154559201 | 05 | TX |   | MEDICAID | 8G7980 | 01 | TX | BC/BS | OTHER | B017 | 01 | NM | TRIWEST | OTHER | 79540 | 05 | NM |   | MEDICAID | 86979Z | 01 | TX | HMO BLUE | OTHER |