| National Provider Identifier [NPI]: | 1467534313 |
| Last Name Of The Provider | DOMINGUEZ |
| First Name Of The Provider | JESSE |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 6604 CHURCHILL ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | SAN BERNARDINO |
| Zip Code Of The Provider | 924072069 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 30 |
| Number Of Services | 381 |
| Number Of Medicare Beneficiaries | 135 |
| Total Submitted Charge Amount | 77556 |
| Total Medicare Allowed Amount | 28948.26 |
| Total Medicare Payment Amount | 19452.57 |
| Total Medicare Standardized Payment Amount | 18846.97 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 45 |
| Number Of Medicare Beneficiaries With Drug Services | 27 |
| Total Drug Submitted ChargeAmount | 1696 |
| Total Drug Medicare AllowedAmount | 550.46 |
| Total Drug Medicare PaymentAmount | 535.95 |
| Total Drug Medicare Standardized Payment Amount | 535.95 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 21 |
| Number Of Medical Services | 336 |
| Number Of Medicare Beneficiaries With Medical Services | 135 |
| Total Medical Submitted Charge Amount | 75860 |
| Total Medical Medicare Allowed Amount | 28397.8 |
| Total Medical Medicare Payment Amount | 18916.62 |
| Total Medical Medicare Standardized Payment Amount | 18311.02 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 25 |
| Number Of Beneficiaries Age 65 to 74 | 62 |
| Number Of Beneficiaries Age 75 to 84 | 27 |
| Number Of Beneficiaries Age Greater 84 | 21 |
| Number Of Female Beneficiaries | 80 |
| Number Of Male Beneficiaries | 55 |
| Number Of Non Hispanic White Beneficiaries | 60 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 60 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 80 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 55 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 21 |
| Percent Of With Chronic Kidney Disease | 27 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 24 |
| Percent Of With Diabetes | 38 |
| Percent Of With Hyperlipidemia | 56 |
| Percent Of With Hypertension | 70 |
| Percent Of With Ischemic Heart Disease | 30 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 44 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.3438 |