Provider Demographics
NPI:1659531721
Name:MICHELE L DOMIANO OD PC
Entity Type:Organization
Organization Name:MICHELE L DOMIANO OD PC
Other - Org Name:DOMIANO EYE CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOMIANO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:570-451-2020
Mailing Address - Street 1:189 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1755
Mailing Address - Country:US
Mailing Address - Phone:570-451-2020
Mailing Address - Fax:570-451-3083
Practice Address - Street 1:189 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1755
Practice Address - Country:US
Practice Address - Phone:570-451-2020
Practice Address - Fax:570-451-3083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000869152W00000X
PAMD0417368152W00000X
PAOE007704T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA058721Medicare PIN
PA5421730001Medicare NSC