Provider Demographics
NPI:1093176141
Name:DOMEK, KATHLEEN G
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:G
Last Name:DOMEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BELLE CIR
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-7054
Mailing Address - Country:US
Mailing Address - Phone:203-502-7637
Mailing Address - Fax:
Practice Address - Street 1:150 BARNUM AVENUE CUT OFF
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614
Practice Address - Country:US
Practice Address - Phone:203-502-7637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT 001614156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician