Provider Demographics
NPI:1386681773
Name:DOMKE, ROBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:DOMKE
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 1:714 N SENATE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3763
Mailing Address - Country:US
Mailing Address - Phone:317-909-3086
Mailing Address - Fax:317-963-2711
Practice Address - Street 1:2598 W WHITE RIVER BLVD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-5251
Practice Address - Country:US
Practice Address - Phone:765-747-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1904522085R0202X
IN01055190A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01870382Medicaid
NY01870382Medicaid
NYG81537Medicare UPIN
INP01803108Medicare PIN