MEDICARE: MARK THOMAS DOMENICK MD

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	207P00000X	Emergency Medicine Physician	D0031179	MD

General Provider Information

NPI Number	:	1770536476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK THOMAS DOMENICK MD

Provider Business Mailing Address
First Line	:	PO BOX 597
Second Line	:
City	:	OAKLAND
State	:	MD
Zip	:	21550-0597
Country	:	US
Telephone Number	:	301-533-4329
Fax Number	:	301-533-4208

Provider Business Practice Location Address
First Line	:	251 N FOURTH STREET
Second Line	:
City	:	OAKLAND
State	:	MD
Zip	:	21550-1375
Country	:	US
Telephone Number	:	301-533-4190
Fax Number	:	301-533-4208

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

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	07/08/2007

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Directions to “ MARK THOMAS DOMENICK MD” Practice Location

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