Provider Demographics
NPI:1184688251
Name:MARINI, DOMENIC (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMENIC
Middle Name:
Last Name:MARINI
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 1:19 OLD KINGS RD N
Mailing Address - Street 2:SUITE C-106
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8260
Mailing Address - Country:US
Mailing Address - Phone:386-446-6540
Mailing Address - Fax:386-447-7732
Practice Address - Street 1:19 OLD KINGS RD N
Practice Address - Street 2:SUITE C-106
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8260
Practice Address - Country:US
Practice Address - Phone:386-446-6540
Practice Address - Fax:386-447-7732
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80454207RI0011X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAX630OtherMEDICARE GROUP NUMBER
FL17609OtherBLUE CROSS BLUE SHIELD
FL17609VMedicare PIN
FLAX630OtherMEDICARE GROUP NUMBER