Provider Demographics
NPI:1013912948
Name:DOMESCEK, RONALD RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:RICHARD
Last Name:DOMESCEK
Suffix:
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 1:1222 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1215
Mailing Address - Country:US
Mailing Address - Phone:407-650-1300
Mailing Address - Fax:407-650-1307
Practice Address - Street 1:1222 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:407-650-1300
Practice Address - Fax:407-650-1307
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57239207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063394100Medicaid
FLME57239OtherMEDICAL LICENSE
FL063394100Medicaid
FLB52471Medicare UPIN
FL10406ZMedicare PIN