Provider Demographics
NPI:1952530974
Name:DOMINA, JASON GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:GLENN
Last Name:DOMINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4201 W MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8409
Mailing Address - Country:US
Mailing Address - Phone:815-334-5566
Mailing Address - Fax:815-759-4008
Practice Address - Street 1:4201 W MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8409
Practice Address - Country:US
Practice Address - Phone:815-334-5566
Practice Address - Fax:815-759-4008
Is Sole Proprietor?:No
Enumeration Date:2009-07-12
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010948622085R0202X
IL0361597752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology