Provider Demographics
NPI:1912110156
Name:ROBERT P DOMALESKI MD PC
Entity Type:Organization
Organization Name:ROBERT P DOMALESKI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:DOMALESKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-421-3331
Mailing Address - Street 1:1930 S FEDERAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219-5501
Mailing Address - Country:US
Mailing Address - Phone:303-935-9142
Mailing Address - Fax:303-934-7332
Practice Address - Street 1:4045 WADSWORTH
Practice Address - Street 2:#100
Practice Address - City:WHEATRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033
Practice Address - Country:US
Practice Address - Phone:303-421-3331
Practice Address - Fax:303-421-1309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODA8406OtherRRW MEDICARE
CO99053781Medicaid
COC477708Medicare PIN
COD24335Medicare UPIN