Provider Demographics
NPI:1568427912
Name:DOMIN, WAYNE D (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:D
Last Name:DOMIN
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 310
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03247-0310
Mailing Address - Country:US
Mailing Address - Phone:603-524-3211
Mailing Address - Fax:603-527-7038
Practice Address - Street 1:96 HIGH STREET
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-3537
Practice Address - Country:US
Practice Address - Phone:603-524-9197
Practice Address - Fax:603-524-9142
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6193207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
020346032OtherTAX ID
NH0105602YONH01OtherANTHEM
NH00000575Medicaid
NH81166895Medicaid
NH00000575Medicaid
NHRE0071Medicare PIN
NHNH6895Medicare ID - Type UnspecifiedGRP
E75461Medicare UPIN