Provider Demographics
NPI:1225136807
Name:DOMS, STEPHEN ROBERT (DPM)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ROBERT
Last Name:DOMS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 9TH AVE N
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-8087
Mailing Address - Country:US
Mailing Address - Phone:952-935-3334
Mailing Address - Fax:952-935-1935
Practice Address - Street 1:29 9TH AVE N
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-8087
Practice Address - Country:US
Practice Address - Phone:952-935-3334
Practice Address - Fax:952-935-1935
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN399213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2715056OtherMEDICA HEALTH PLAN
FM04153DOOtherBLUE SHIELD
MN2715056OtherMEDICA HEALTH PLAN