Healthcare Provider Details

I. General information

NPI: 1225004922
Provider Name (Legal Business Name): DAVID JOHN DOMENICHINI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 COTTAGE GROVE RD STE B220
BLOOMFIELD CT
06002-3077
US

IV. Provider business mailing address

701 COTTAGE GROVE RD STE B220
BLOOMFIELD CT
06002-3077
US

V. Phone/Fax

Practice location:
  • Phone: 860-561-1007
  • Fax: 860-561-1222
Mailing address:
  • Phone: 860-561-1007
  • Fax: 860-561-1222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number032306
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001323063
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: