Provider Demographics
NPI:1164473880
Name:DOMEK, DAVID BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRADLEY
Last Name:DOMEK
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 1:3366 NW EXPRESSWAY
Mailing Address - Street 2:SUITE 33
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4462
Mailing Address - Country:US
Mailing Address - Phone:405-945-4525
Mailing Address - Fax:405-945-4535
Practice Address - Street 1:3366 NW EXPRESSWAY
Practice Address - Street 2:SUITE 330
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4462
Practice Address - Country:US
Practice Address - Phone:405-945-4525
Practice Address - Fax:405-945-4535
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15857174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE64498Medicare UPIN