Provider Demographics
NPI:1558534263
Name:DOMAH, NAU DEAVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:NAU
Middle Name:DEAVIN
Last Name:DOMAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 BREMO ROAD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1930
Mailing Address - Country:US
Mailing Address - Phone:804-288-3079
Mailing Address - Fax:804-282-6159
Practice Address - Street 1:5855 BREMO ROAD
Practice Address - Street 2:SUITE 207
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1930
Practice Address - Country:US
Practice Address - Phone:804-288-3079
Practice Address - Fax:804-282-6159
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091486207R00000X
VA0101245571207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C05700OtherGROUP PTAN
VAC06695OtherGROUP PTAN
VAC06778OtherGROUP PTAN