Provider Demographics
NPI:1730106329
Name:DOMM, BRUCE L (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:DOMM
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:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:5 9TH AVE N
Practice Address - Street 2:
Practice Address - City:CASSELTON
Practice Address - State:ND
Practice Address - Zip Code:58012-3339
Practice Address - Country:US
Practice Address - Phone:701-347-4445
Practice Address - Fax:701-347-5276
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5341207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND37983OtherSIOUX VALLEY #
ND0106110OtherMEDICA #
ND0108127OtherMEDICA #
ND112583400Medicaid
ND142308OtherUCARE #
MNND100038OtherLHS #
ND0106108OtherMEDICA #
ND15375Medicaid
ND93416DOOtherMNBS 3
NDHP19507OtherHEALTHPARTNERS #
ND336OtherNDBS #
NDDA9011015505OtherPREFERRED ONE #
ND00A28DOOtherMNBS #
ND676560OtherAMERICA'S PPO/ARAZ #
ND93416DOOtherMNBS #
ND676560OtherAMERICA'S PPO/ARAZ #
ND14496Medicare ID - Type UnspecifiedND MEDICARE #
ND336Medicare ID - Type UnspecifiedND MEDICARE #
MN089004371Medicare ID - Type UnspecifiedMN MEDICARE #
ND080039827Medicare ID - Type UnspecifiedRR MEDICARE #