Provider Demographics
NPI:1053396127
Name:DOMINGO, MARY ANN R (MD)
Entity type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:R
Last Name:DOMINGO
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:6901 N MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8022
Practice Address - Country:US
Practice Address - Phone:574-647-4500
Practice Address - Fax:574-647-6354
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061323A207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000803598OtherBCBS MAIN STREET
IN200537970Medicaid
IN000000803598OtherBCBS MAIN STREET
IN000000391628OtherBCBS BMG LAPORTE
INP00276690OtherRR MEDICARE
IN236040005Medicare PIN
IN565800G6Medicare PIN
IN200537970Medicaid
IN000000803598OtherBCBS MAIN STREET