Provider Demographics
NPI:1841281557
Name:DOMSON, CHARLES L II (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:DOMSON
Suffix:II
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 1:212 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5103
Mailing Address - Country:US
Mailing Address - Phone:352-435-0723
Mailing Address - Fax:352-435-0724
Practice Address - Street 1:212 N 2ND ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5103
Practice Address - Country:US
Practice Address - Phone:352-435-0723
Practice Address - Fax:352-435-0724
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME730192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256714802Medicaid
FL46423FMedicare PIN
FL256714802Medicaid
FL46423EMedicare PIN
FL46423UMedicare PIN