Provider Demographics
NPI:1558603381
Name:EDWARD J. DOMANSKIS,MD INC.
Entity Type:Organization
Organization Name:EDWARD J. DOMANSKIS,MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMANSKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-331-8390
Mailing Address - Street 1:175 N REDWOOD DR
Mailing Address - Street 2:SUITE 275
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1972
Mailing Address - Country:US
Mailing Address - Phone:415-331-8390
Mailing Address - Fax:
Practice Address - Street 1:1441 AVOCADO AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7721
Practice Address - Country:US
Practice Address - Phone:949-640-9324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22703208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1023139128OtherTYPE 1 NPI