Provider Demographics
NPI:1235165440
Name:DOMASHEVICH, VITALIY (MD)
Entity Type:Individual
Prefix:DR
First Name:VITALIY
Middle Name:
Last Name:DOMASHEVICH
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:PO BOX 3405
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80155-3405
Mailing Address - Country:US
Mailing Address - Phone:720-870-7446
Mailing Address - Fax:720-870-7460
Practice Address - Street 1:14100 E ARAPAHOE RD
Practice Address - Street 2:SUITE B110
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-4028
Practice Address - Country:US
Practice Address - Phone:720-870-7446
Practice Address - Fax:720-870-7460
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO041756207L00000X
CO41756207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0971244Medicaid
COC811774Medicare PIN
COCOA103512Medicare PIN
COH72737Medicare UPIN
CO0971244Medicaid