Provider Demographics
NPI:1023278967
Name:ROMA, DOMENICK J (MD)
Entity type:Individual
Prefix:
First Name:DOMENICK
Middle Name:J
Last Name:ROMA
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 1:4700 WATERS AVE STE 507
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-4750
Mailing Address - Fax:912-350-4751
Practice Address - Street 1:4700 WATERS AVE STE 507
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-4750
Practice Address - Fax:912-350-4751
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC148977390200000X
GA070901207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003143431AMedicaid
GAP01289982OtherRAILROAD MEDICARE
SCGA1598Medicaid
GA202I296342Medicare PIN