Healthcare Provider Details

I. General information

NPI: 1265845010
Provider Name (Legal Business Name): MARK DOMAAS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S CALIFORNIA AVE
CHICAGO IL
60608-1732
US

IV. Provider business mailing address

4450 31ST AVE S STE 102
FARGO ND
58104-4557
US

V. Phone/Fax

Practice location:
  • Phone: 773-542-2000
  • Fax:
Mailing address:
  • Phone: 701-561-3312
  • Fax: 701-232-5578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005716
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number82
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: