Healthcare Provider Details

I. General information

NPI: 1154454635
Provider Name (Legal Business Name): BENJAMIN DOMB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 E TOUHY AVE STE 450
DES PLAINES IL
60018-2748
US

IV. Provider business mailing address

999 E TOUHY AVE STE 450
DES PLAINES IL
60018-2748
US

V. Phone/Fax

Practice location:
  • Phone: 630-920-2323
  • Fax: 630-323-5625
Mailing address:
  • Phone: 630-920-2323
  • Fax: 630-323-5625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036119758
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: