Provider Demographics
NPI:1891763058
Name:DOMDERA, RICHARD JAMES JR (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JAMES
Last Name:DOMDERA
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 1:3009 SMITH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-2666
Mailing Address - Country:US
Mailing Address - Phone:330-836-8471
Mailing Address - Fax:
Practice Address - Street 1:3009 SMITH RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-2666
Practice Address - Country:US
Practice Address - Phone:330-836-8471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077042D207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH729920OtherBUCKEYE COMMUNITY INSURAN
OH000000312579OtherANTHEM INSURANCE
OHP00121516OtherRAILROAD MEDICARE
OH374OtherSUMMACARE INSURANCE
OHQ004524OtherHOMETOWN INSURANCE
OH2283176Medicaid
OH97033OtherQUALCHOICE
OH374OtherSUMMACARE INSURANCE
OHH48681Medicare UPIN