Provider Demographics
NPI:1790761831
Name:DOMLOJ, NERVANE TAREK (MD)
Entity Type:Individual
Prefix:DR
First Name:NERVANE
Middle Name:TAREK
Last Name:DOMLOJ
Suffix:
Gender:F
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 636256
Mailing Address - Street 2:CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5502
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:7700 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-2505
Practice Address - Country:US
Practice Address - Phone:513-585-5502
Practice Address - Fax:513-585-5511
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081404207L00000X
OH35.093999207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2988950Medicaid
IN201006520Medicaid
KY7100140720Medicaid
OHH045680Medicare PIN
OHDE4274191Medicare PIN