Provider Demographics
NPI:1669497038
Name:DOMINICK, JUSTIN E (MD)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:E
Last Name:DOMINICK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:18370 BURBANK BLVD
Mailing Address - Street 2:107
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2813
Mailing Address - Country:US
Mailing Address - Phone:818-996-3880
Mailing Address - Fax:818-996-1679
Practice Address - Street 1:18370 BURBANK BLVD
Practice Address - Street 2:107
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2813
Practice Address - Country:US
Practice Address - Phone:818-996-3880
Practice Address - Fax:818-996-1679
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2009-04-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA751562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A751560Medicaid
CA00A751560Medicaid
CAWA75156EMedicare PIN