Provider Demographics
NPI:1629012661
Name:DOMANICK, THOMAS M (DP,M,)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:DOMANICK
Suffix:
Gender:M
Credentials:DP,M,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 MAIN ST
Mailing Address - Street 2:SUITE 216
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-5369
Mailing Address - Country:US
Mailing Address - Phone:203-377-1777
Mailing Address - Fax:
Practice Address - Street 1:1825 BARNUM AVE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-5333
Practice Address - Country:US
Practice Address - Phone:203-377-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTP00289213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004051868Medicaid
CT0V2746OtherHEALTH NET
CTZS701OtherOXFORD
CT004144309OtherMEDICAID DME
CT0V2746OtherHEALTH NET SMART CHOICE
CT0071014OtherAETNA
CT030000289CT02OtherANTHEM BC/BS
CTT22076Medicare UPIN
CT0773490001Medicare NSC
CT004051868Medicaid