Provider Demographics
NPI:1508012030
Name:DOMANSKI, DAMIAN JERZY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAMIAN
Middle Name:JERZY
Last Name:DOMANSKI
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 741729
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1160 E 3900 S STE 2000
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1236
Practice Address - Country:US
Practice Address - Phone:801-266-3418
Practice Address - Fax:801-266-4174
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11493948-1205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0092152Medicaid
KY7100268970Medicaid
OH0092152Medicaid