Provider Demographics
NPI:1982675062
Name:DOMIN, DAVID J (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:DOMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 37615
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85069-7615
Mailing Address - Country:US
Mailing Address - Phone:602-277-2268
Mailing Address - Fax:602-944-2543
Practice Address - Street 1:5133 N CENTRAL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1438
Practice Address - Country:US
Practice Address - Phone:602-264-8015
Practice Address - Fax:602-264-2172
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2012-08-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ30234207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ761032Medicaid
AZAZ0721260OtherBLUECROSS BLUESHIELD AZ
AZD07961Medicare UPIN
AZ72157Medicare ID - Type Unspecified