Healthcare Provider Details

I. General information

NPI: 1831108455
Provider Name (Legal Business Name): WILLIAM K. DOMARAD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE STE 460
VANCOUVER WA
98664-1965
US

IV. Provider business mailing address

814 E 65TH S
IDAHO FALLS ID
83404-7662
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-7771
  • Fax: 360-514-7769
Mailing address:
  • Phone: 605-939-5526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number7330
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberDO-04320
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number02003790A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberO-1291
License Number StateID
# 5
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberOP00001949
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: