Provider Demographics
NPI:1770582678
Name:DOMBROSKI, WALTER W (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:W
Last Name:DOMBROSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 SOUTHEAST BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-3464
Mailing Address - Country:US
Mailing Address - Phone:330-332-7685
Mailing Address - Fax:330-332-7724
Practice Address - Street 1:2235 E PERSHING ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-3478
Practice Address - Country:US
Practice Address - Phone:330-332-7803
Practice Address - Fax:330-332-7604
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-8775207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0597260Medicaid
OH0597260Medicaid
OH9269143Medicare PIN