Healthcare Provider Details

I. General information

NPI: 1265406730
Provider Name (Legal Business Name): MICHELE L DOMIANO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 N MAIN ST
OLD FORGE PA
18518
US

IV. Provider business mailing address

189 N MAIN ST
OLD FORGE PA
18518
US

V. Phone/Fax

Practice location:
  • Phone: 570-451-2020
  • Fax: 570-451-3083
Mailing address:
  • Phone: 570-451-2020
  • Fax: 570-451-3083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000869
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMD0417368
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEO07704T
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: