Provider Demographics
NPI:1780983437
Name:KING, DOMINIC M (DO)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:M
Last Name:KING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE # DESKA4
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-444-8960
Mailing Address - Fax:440-239-0979
Practice Address - Street 1:7010 ENGLE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-8401
Practice Address - Country:US
Practice Address - Phone:440-260-3731
Practice Address - Fax:440-239-0979
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.004005207Q00000X
OH3401178207XX0005X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0133672Medicaid
OH0133672Medicaid