Provider Demographics
NPI:1417945056
Name:DOMERACKI, FRANK R (MD)
Entity Type:Individual
Prefix:DR
First Name:FRANK
Middle Name:R
Last Name:DOMERACKI
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 6750
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03802-6750
Mailing Address - Country:US
Mailing Address - Phone:800-208-7069
Mailing Address - Fax:610-956-0009
Practice Address - Street 1:1200 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-3720
Practice Address - Country:US
Practice Address - Phone:215-481-3926
Practice Address - Fax:215-481-4126
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042173E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016175980002Medicaid
PA884133D2HMedicare PIN
PA884133F66Medicare PIN
PA0016175980002Medicaid
G37858Medicare UPIN