Provider Demographics
NPI:1629233861
Name:DOMINIK, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DOMINIK
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 1:755 JEFFERSON RD
Mailing Address - Street 2:STE 110
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-3233
Mailing Address - Country:US
Mailing Address - Phone:585-419-7948
Mailing Address - Fax:585-385-6071
Practice Address - Street 1:755 JEFFERSON RD
Practice Address - Street 2:STE 110
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-3233
Practice Address - Country:US
Practice Address - Phone:585-419-7948
Practice Address - Fax:585-385-6071
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104326207RS0012X, 2084N0400X
MN521962084N0400X
FLME989362084N0400X
NY2575202084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
NY03400199Medicaid
MNENROLLEDMedicaid
NYP010257520OtherEXCELLUS
MNP00804268OtherMEDICARE - RAILROAD
MN130001475Medicare PIN
MNP00804268OtherMEDICARE - RAILROAD