Provider Demographics
NPI:1952539280
Name:DOMZALSKI, JEROME TAYMON (MD)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:TAYMON
Last Name:DOMZALSKI
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 1:111 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1853
Mailing Address - Country:US
Mailing Address - Phone:309-740-4272
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-4748
Practice Address - Country:US
Practice Address - Phone:309-655-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1859312085R0202X
WAMD608086742085R0202X
IDM-146692085R0202X
IL036-1644442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0384868OtherLNI TRA-MINW, PS REST OF WA COUNTIES
WA0384886OtherLNI DINW
WA0408166OtherLNI RADIA REST OF WA
WA0384879OtherLNI TRA-MINW, PS KING COUNTY
WA0408173OtherLNI EVERGREEN RADIA
WA2094399Medicaid
WA0384883OtherLNI UAOM
WA0408171OtherLNI SWEDISH RADIA EDMONDS
WA0408174OtherLNI SOUTH SOUND RADIOLOGY
WA0408176OtherLNI SEATTLE RADIOLOGY
WA0408168OtherLNI RADIA KING COUNTY