Healthcare Provider Details

I. General information

NPI: 1922006204
Provider Name (Legal Business Name): ANTHONY M DOMINIC SR DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 01/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 S IRONWOOD DR STE 104
APACHE JUNCTION AZ
85220-6242
US

IV. Provider business mailing address

850 S IRONWOOD DR STE 104
APACHE JUNCTION AZ
85220-6242
US

V. Phone/Fax

Practice location:
  • Phone: 480-982-1265
  • Fax: 480-982-8831
Mailing address:
  • Phone: 480-982-1265
  • Fax: 480-982-8831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34002451
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1833
License Number StateAZ

VIII. Authorized Official

Name: DR. ANTHONY M DOMINIC SR.
Title or Position: PRESIDENT
Credential: DO
Phone: 480-982-1265