MEDICARE: DR. DAVID J DOMIN 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	207L00000X	Anesthesiology Physician	30234	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	AZ0721260	OTHER	AZ	BLUECROSS BLUESHIELD AZ

General Provider Information

NPI Number	:	1982675062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID J DOMIN MD

Provider Business Mailing Address
First Line	:	PO BOX 37615
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85069-7615
Country	:	US
Telephone Number	:	602-277-2268
Fax Number	:	602-944-2543

Provider Business Practice Location Address
First Line	:	5133 N CENTRAL AVE
Second Line	:	SUITE 200
City	:	PHOENIX
State	:	AZ
Zip	:	85012-1438
Country	:	US
Telephone Number	:	602-264-8015
Fax Number	:	602-264-2172

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

Provider Enumeration Date	:	01/27/2006
Last Update Date	:	08/13/2012

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Directions to “ DR. DAVID J DOMIN MD” Practice Location

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