Provider Demographics
NPI:1952359267
Name:DOMENICI, LOUIS JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:JOSEPH
Last Name:DOMENICI
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:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8769
Mailing Address - Fax:410-328-3577
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-8769
Practice Address - Fax:410-328-3577
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD22422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD525249-04OtherBLUE CROSS/BLUE SHIELD
VA5850681Medicaid
MD375781100Medicaid
WV3810000274Medicaid
MD309570-02OtherBLUE CROSS/BLUE SHIELD
D84650Medicare UPIN
VA5850681Medicaid
MDS085G190Medicare PIN