Healthcare Provider Details

I. General information

NPI: 1205018470
Provider Name (Legal Business Name): DAVID J DOMENICHINI MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2007
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 TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number032306
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number032306
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number032306
License Number StateCT

VIII. Authorized Official

Name: DR. DAVID J DOMENICHINI
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 860-561-1007