Healthcare Provider Details

I. General information

NPI: 1205875655
Provider Name (Legal Business Name): DONALD JAMES DOMRATH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 CALUMET AVE
MANITOWOC WI
54220-5427
US

IV. Provider business mailing address

7711 HOMESTEAD RD
WHITELAW WI
54247-9710
US

V. Phone/Fax

Practice location:
  • Phone: 920-683-2244
  • Fax:
Mailing address:
  • Phone: 920-684-5127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1317
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier38567200
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: