Provider Demographics
NPI:1205018470
Name:DAVID J DOMENICHINI MD, PC
Entity type:Organization
Organization Name:DAVID J DOMENICHINI MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOMENICHINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-561-1007
Mailing Address - Street 1:701 COTTAGE GROVE RD STE B220
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3077
Mailing Address - Country:US
Mailing Address - Phone:860-561-1007
Mailing Address - Fax:860-561-1222
Practice Address - Street 1:701 COTTAGE GROVE RD STE B220
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3077
Practice Address - Country:US
Practice Address - Phone:860-561-1007
Practice Address - Fax:860-561-1222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032306207R00000X, 363L00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03887OtherMEDICARE GROUP
CT50DOMENICCT01OtherANTHEM BLUE CROSS/ BLUE SHIELD GROUP
CT500000218OtherMEDICAID GROUP
CT500000332OtherMEDICAID APRN GROUP
CTDH2482OtherMEDICARE RAILROAD GROUP