Provider Demographics
NPI:1023405297
Name:BLUEMONT PLASTIC SURGERY, PC
Entity type:Organization
Organization Name:BLUEMONT PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:DOMANSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-596-1660
Mailing Address - Street 1:8316 ARLINGTON BLVD STE 524
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-5216
Mailing Address - Country:US
Mailing Address - Phone:703-596-1660
Mailing Address - Fax:
Practice Address - Street 1:8316 ARLINGTON BLVD STE 524
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-5216
Practice Address - Country:US
Practice Address - Phone:703-596-1660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-24
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101257764207Y00000X, 208200000X
2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty