Provider Demographics
NPI:1821062332
Name:DOMMERS, MARTIN P JR (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:P
Last Name:DOMMERS
Suffix:JR
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 1247
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30015-1247
Mailing Address - Country:US
Mailing Address - Phone:803-462-3770
Mailing Address - Fax:803-462-3771
Practice Address - Street 1:2000 PARK ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2011
Practice Address - Country:US
Practice Address - Phone:803-462-3770
Practice Address - Fax:803-462-3771
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC120882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCB92468Medicare UPIN