Provider Demographics
NPI:1144209552
Name:DOMBROSKI, RICHARD TODD (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:TODD
Last Name:DOMBROSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:TODD
Other - Middle Name:
Other - Last Name:DOMBROSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:8332 WHIPPOORWILL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-1994
Mailing Address - Country:US
Mailing Address - Phone:817-412-0877
Mailing Address - Fax:
Practice Address - Street 1:6913 CAMP BOWIE BLVD STE 107
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-7164
Practice Address - Country:US
Practice Address - Phone:817-367-9289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3358207Q00000X, 207QS0010X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8FA812OtherBCBS
TXP01609114OtherRAILROAD MEDICARE
TX344044804Medicaid
TX8FA814OtherBCBS
TX344044801Medicaid
TX8FA814OtherBCBS
TX344044804Medicaid