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General NPI Number Information
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NPI Number | 1629012661
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Entity Type | Individual
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Provider Name | THOMAS M DOMANICK D.P,M,
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Gender | Male
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Dates
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Enumeration Date | 06/16/2006
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Last Update Date | 01/07/2015
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Provider Practice Location Address
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Address Line | 1825 BARNUM AVE
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City | STRATFORD
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State | CT
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Zip | 06614-5333
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Country | US
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Telephone | 203-377-1777
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Fax |
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Provider Business Mailing Address
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Address Line | 2660 MAIN ST SUITE 216
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City | BRIDGEPORT
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State | CT
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Zip | 06606-5369
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Country | US
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Telephone | 203-377-1777
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213EP1101X
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Taxonomy Name | Primary Podiatric Medicine Podiatrist
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License Number | P00289
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | P00289
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License Number State | CT
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