Provider Demographics
NPI:1003872474
Name:DOMER, GREGORY S (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:DOMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 OSTRUM ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1000
Mailing Address - Country:US
Mailing Address - Phone:484-503-8281
Mailing Address - Fax:833-816-5612
Practice Address - Street 1:3735 NAZARETH RD STE 206
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-8346
Practice Address - Country:US
Practice Address - Phone:484-503-8281
Practice Address - Fax:833-866-5612
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4271772086S0129X
NJ25MA072508002086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101443016 0001Medicaid
PA097101 URZMedicare ID - Type Unspecified
PAH86657Medicare UPIN