Provider Demographics
NPI:1396727988
Name:DOMINO, TERRY GAYLE (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:GAYLE
Last Name:DOMINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1835 WEST COUNTY ROAD C
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1304
Mailing Address - Country:US
Mailing Address - Phone:763-785-4300
Mailing Address - Fax:763-785-3314
Practice Address - Street 1:1835 WEST COUNTY ROAD C
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1304
Practice Address - Country:US
Practice Address - Phone:763-785-4300
Practice Address - Fax:763-785-3314
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN22141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN33858500CMedicaid
MN33858500CMedicaid