Provider Demographics
NPI:1033225214
Name:DAVID J DOMIN MD PC
Entity Type:Organization
Organization Name:DAVID J DOMIN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-264-1395
Mailing Address - Street 1:5133 N CENTRAL AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1438
Mailing Address - Country:US
Mailing Address - Phone:602-264-1395
Mailing Address - Fax:602-264-2172
Practice Address - Street 1:5133 N CENTRAL AVE
Practice Address - Street 2:STE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1438
Practice Address - Country:US
Practice Address - Phone:602-264-1395
Practice Address - Fax:602-264-2172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30234174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0721260OtherBLUE CROSS BLUE SHIELD AZ
AZ761032Medicaid
AZ761032Medicaid