Healthcare Provider Details

I. General information

NPI: 1629012661
Provider Name (Legal Business Name): THOMAS M DOMANICK D.P,M,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 BARNUM AVE
STRATFORD CT
06614-5333
US

IV. Provider business mailing address

2660 MAIN ST SUITE 216
BRIDGEPORT CT
06606-5369
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberP00289
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberP00289
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: