Provider Demographics
NPI:1235540386
Name:DOMACK, TERESA (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:DOMACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 SOUTH RD STE 110
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2482
Mailing Address - Country:US
Mailing Address - Phone:860-284-4945
Mailing Address - Fax:860-284-4946
Practice Address - Street 1:21 SOUTH RD STE 110
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032
Practice Address - Country:US
Practice Address - Phone:860-284-4945
Practice Address - Fax:860-284-4946
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT62215208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist