Healthcare Provider Details

I. General information

NPI: 1366423022
Provider Name (Legal Business Name): PATRICK W DOMKOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 S HARBOR CITY BLVD STE 430
MELBOURNE FL
32901-5591
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-344-8746
  • Fax: 321-339-1932
Mailing address:
  • Phone: 321-344-8746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME89469
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: