Provider Demographics
NPI:1437750874
Name:DYMARCZYK, DOMINIKA MARIA
Entity Type:Individual
Prefix:
First Name:DOMINIKA
Middle Name:MARIA
Last Name:DYMARCZYK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-410-3524
Mailing Address - Fax:510-506-7722
Practice Address - Street 1:2500 MILVIA ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2636
Practice Address - Country:US
Practice Address - Phone:510-410-3524
Practice Address - Fax:510-506-7722
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANM2636176367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA236176OtherSTATE MEDICAL LICENSE