Provider Demographics
NPI:1619529278
Name:DOMAGOLA, AMANDA (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:DOMAGOLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 WESTHAMPTON STA
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3330
Mailing Address - Country:US
Mailing Address - Phone:804-287-4200
Mailing Address - Fax:
Practice Address - Street 1:451 HOLLYBROOK RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-4115
Practice Address - Country:US
Practice Address - Phone:585-354-5337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-14
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002756152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist