MEDICARE: JAMES DOMESEK 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	2085R0204X	Vascular & Interventional Radiology Physician	MD039114L	PA
2	2085R0204X	Vascular & Interventional Radiology Physician	ME86904	FL

General Provider Information

NPI Number	:	1831180082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES DOMESEK MD

Provider Business Mailing Address
First Line	:	1314 E LAS OLAS BLVD STE 898
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2334
Country	:	US
Telephone Number	:	954-540-5410
Fax Number	:	772-460-6563

Provider Business Practice Location Address
First Line	:	1314 E LAS OLAS BLVD STE 898
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2334
Country	:	US
Telephone Number	:	954-540-5410
Fax Number	:	772-460-6563

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

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	07/31/2018

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