Healthcare Provider Details

I. General information

NPI: 1588668289
Provider Name (Legal Business Name): MICHAEL F DOMBEK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 HIGHWAY 54 W STE 205
PEACHTREE CITY GA
30269-4794
US

IV. Provider business mailing address

265 N JEFF DAVIS DR
FAYETTEVILLE GA
30214-1668
US

V. Phone/Fax

Practice location:
  • Phone: 678-561-9000
  • Fax: 770-487-1232
Mailing address:
  • Phone: 770-716-8732
  • Fax: 770-716-8878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000954
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: