Provider Demographics
NPI:1720633373
Name:MARK E DOMAAS LLC
Entity Type:Organization
Organization Name:MARK E DOMAAS LLC
Other - Org Name:ADVANCED FOOT & ANKLE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DOMAAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:701-561-3312
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 STE 102
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4557
Practice Address - Country:US
Practice Address - Phone:763-218-4771
Practice Address - Fax:701-205-4593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-09
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty