Healthcare Provider Details

I. General information

NPI: 1235316597
Provider Name (Legal Business Name): THOMAS M DOMANICK DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 BARNUM AVE
STRATFORD CT
06614-5333
US

IV. Provider business mailing address

1825 BARNUM AVE SUITE 302
STRATFORD CT
06614-5333
US

V. Phone/Fax

Practice location:
  • Phone: 203-377-1777
  • Fax: 203-378-8348
Mailing address:
  • Phone: 203-377-1777
  • Fax: 203-378-8348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberPOO289
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPOO289
License Number StateCT

VIII. Authorized Official

Name: THOMAS M DOMANICK
Title or Position: OWNER
Credential: D,P.M.
Phone: 203-377-1777