Healthcare Provider Details

I. General information

NPI: 1235767021
Provider Name (Legal Business Name): ALEXANDER JOSEPH DOMOZICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2020
Last Update Date: 01/19/2025
Certification Date: 01/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 OAKFIELD DR
BRANDON FL
33511-5779
US

IV. Provider business mailing address

816 CALICO SCALLOP ST
RUSKIN FL
33570-8098
US

V. Phone/Fax

Practice location:
  • Phone: 813-916-2347
  • Fax:
Mailing address:
  • Phone: 440-715-3055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME162684
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: