Provider Demographics
NPI:1083793905
Name:DOMASH, MICHAEL DENNIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DENNIS
Last Name:DOMASH
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 1:2215 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-3226
Mailing Address - Country:US
Mailing Address - Phone:360-906-7156
Mailing Address - Fax:360-696-3658
Practice Address - Street 1:2215 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3226
Practice Address - Country:US
Practice Address - Phone:360-906-7156
Practice Address - Fax:360-696-3658
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000177852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry