MEDICARE: DIANA S DOMNITEI MD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	MD155672	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1639361868	OTHER	OR	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1538601737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIANA S DOMNITEI MD LLC

Provider Business Mailing Address
First Line	:	1012 SW KING AVE STE 306
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-1110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1012 SW KING AVE STE 306
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-1110
Country	:	US
Telephone Number	:	503-467-8763
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DIANA SIDONIA DOMNITEI
Credential	:	MD
Telephone Number	:	503-467-8763

Provider Enumeration Date	:	11/06/2016
Last Update Date	:	11/06/2016

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