MEDICARE: DR. ILLY DOMINITZ M.D.

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	2083P0500X	Preventive Medicine/Occupational Environmental Medicine Physician	0101228195	VA

General Provider Information

NPI Number	:	1649317553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ILLY DOMINITZ M.D.

Provider Business Mailing Address
First Line	:	1468 INGRAM ST
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23551-2596
Country	:	US
Telephone Number	:	757-836-1685
Fax Number	:	757-836-1528

Provider Business Practice Location Address
First Line	:	1468 INGRAM ST
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23551-2596
Country	:	US
Telephone Number	:	757-836-1685
Fax Number	:	757-836-1528

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	07/08/2007

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