Provider Demographics
NPI:1235316597
Name:THOMAS M DOMANICK DPM
Entity Type:Organization
Organization Name:THOMAS M DOMANICK DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOMANICK
Authorized Official - Suffix:
Authorized Official - Credentials:D,PM
Authorized Official - Phone:203-377-1777
Mailing Address - Street 1:1825 BARNUM AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-5333
Mailing Address - Country:US
Mailing Address - Phone:203-377-1777
Mailing Address - Fax:203-378-8348
Practice Address - Street 1:1825 BARNUM AVE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-5333
Practice Address - Country:US
Practice Address - Phone:203-377-1777
Practice Address - Fax:203-378-8348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPOO289208600000X, 213ES0131X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0773490001Medicare NSC
CT0773490001Medicare PIN