Provider Demographics
NPI:1265845010
Name:DOMAAS, MARK (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:DOMAAS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4450 31ST AVE S STE 102
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4557
Mailing Address - Country:US
Mailing Address - Phone:701-561-3312
Mailing Address - Fax:701-232-5578
Practice Address - Street 1:4450 31ST AVE S
Practice Address - Street 2:STE 102
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4557
Practice Address - Country:US
Practice Address - Phone:701-566-8721
Practice Address - Fax:701-205-4593
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005716213E00000X
ND82213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist