MEDICARE: ANTHONY M DOMINIC SR DO PC

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	207Q00000X	Family Medicine Physician	34002451	OH
2	207Q00000X	Family Medicine Physician	1833	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1Z0948	OTHER	AZ	HEALTHNET
3	AZ0390340	OTHER	AZ	BCBS

General Provider Information

NPI Number	:	1922006204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTHONY M DOMINIC SR DO PC

Provider Business Mailing Address
First Line	:	850 S IRONWOOD DR
Second Line	:	STE 104
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85220-6242
Country	:	US
Telephone Number	:	480-982-1265
Fax Number	:	480-982-8831

Provider Business Practice Location Address
First Line	:	850 S IRONWOOD DR
Second Line	:	STE 104
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85220-6242
Country	:	US
Telephone Number	:	480-982-1265
Fax Number	:	480-982-8831

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANTHONY M DOMINIC SR.
Credential	:	DO
Telephone Number	:	480-982-1265

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	01/14/2008

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