Provider Demographics
NPI:1912529132
Name:DOMBY, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:DOMBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 LEE HWY STE 6
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-5958
Mailing Address - Country:US
Mailing Address - Phone:276-645-0823
Mailing Address - Fax:
Practice Address - Street 1:3101 LEE HWY STE 6
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-5958
Practice Address - Country:US
Practice Address - Phone:276-645-0823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2101002200237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2101002200OtherVIRGINIA DPOR