Provider Demographics
NPI:1922006204
Name:ANTHONY M DOMINIC SR DO PC
Entity Type:Organization
Organization Name:ANTHONY M DOMINIC SR DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOMINIC
Authorized Official - Suffix:SR
Authorized Official - Credentials:DO
Authorized Official - Phone:480-982-1265
Mailing Address - Street 1:850 S IRONWOOD DR
Mailing Address - Street 2:STE 104
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85220-6242
Mailing Address - Country:US
Mailing Address - Phone:480-982-1265
Mailing Address - Fax:480-982-8831
Practice Address - Street 1:850 S IRONWOOD DR
Practice Address - Street 2:STE 104
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85220-6242
Practice Address - Country:US
Practice Address - Phone:480-982-1265
Practice Address - Fax:480-982-8831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1833207Q00000X
OH34002451207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ160127Medicaid
AZ1Z0948OtherHEALTHNET
AZAZ0390340OtherBCBS
AZAZ0390340OtherBCBS
AZ25100Medicare PIN