Provider Demographics
NPI:1013913391
Name:DOMAN, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:DOMAN
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:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-235-4191
Mailing Address - Fax:423-235-7092
Practice Address - Street 1:260 HIGHWAY 11 E
Practice Address - Street 2:
Practice Address - City:BULLS GAP
Practice Address - State:TN
Practice Address - Zip Code:37711-3416
Practice Address - Country:US
Practice Address - Phone:423-235-4191
Practice Address - Fax:423-235-7092
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3094672Medicaid
TN3094672Medicaid
10311I2665Medicare PIN
TNC47134Medicare UPIN
TN103I116051Medicare PIN