Healthcare Provider Details

I. General information

NPI: 1225115363
Provider Name (Legal Business Name): MARK R. DOMAN, M.D. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 N MAIN ST
BULLS GAP TN
37711-4735
US

IV. Provider business mailing address

PO BOX 70
BULLS GAP TN
37711-0070
US

V. Phone/Fax

Practice location:
  • Phone: 423-235-0063
  • Fax: 423-235-0066
Mailing address:
  • Phone: 423-235-0063
  • Fax: 423-235-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number21947
License Number StateTN

VIII. Authorized Official

Name: MARK RICHARD DOMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 423-235-0063