Provider Demographics
NPI:1376752683
Name:DOMYAN, GREGORY ALLEN (MPT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALLEN
Last Name:DOMYAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3580 RIDGESTONE DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-8427
Mailing Address - Country:US
Mailing Address - Phone:419-610-8497
Mailing Address - Fax:
Practice Address - Street 1:335 GLESSNER AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2269
Practice Address - Country:US
Practice Address - Phone:419-526-8000
Practice Address - Fax:419-526-8151
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT.010306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist