Provider Demographics
NPI:1225115363
Name:MARK R. DOMAN, M.D. P.C.
Entity Type:Organization
Organization Name:MARK R. DOMAN, M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-235-0063
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:BULLS GAP
Mailing Address - State:TN
Mailing Address - Zip Code:37711-0070
Mailing Address - Country:US
Mailing Address - Phone:423-235-0063
Mailing Address - Fax:423-235-0066
Practice Address - Street 1:113 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BULLS GAP
Practice Address - State:TN
Practice Address - Zip Code:37711-4735
Practice Address - Country:US
Practice Address - Phone:423-235-0063
Practice Address - Fax:423-235-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21947261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3726855Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER