Provider Demographics
NPI:1831180082
Name:DOMESEK, JAMES (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:DOMESEK
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 1:1314 E LAS OLAS BLVD STE 898
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2334
Mailing Address - Country:US
Mailing Address - Phone:954-540-5410
Mailing Address - Fax:772-460-6563
Practice Address - Street 1:1314 E LAS OLAS BLVD STE 898
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2334
Practice Address - Country:US
Practice Address - Phone:954-540-5410
Practice Address - Fax:772-460-6563
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039114L2085R0204X
FLME869042085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
065522TAYMedicare ID - Type Unspecified
C28736Medicare UPIN