1255328415 NPI number — DR. JENNIFER HOLLAR DOMER MD

Table of content: CLAIRE WEISS PH.D. (NPI 1063536761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255328415 NPI number — DR. JENNIFER HOLLAR DOMER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMER
Provider First Name:
JENNIFER
Provider Middle Name:
HOLLAR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255328415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7023 OLD JAHNKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23225-4126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-320-1353
Provider Business Mailing Address Fax Number:
804-320-6636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7023 OLD JAHNKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23225-4126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-320-1353
Provider Business Practice Location Address Fax Number:
804-320-6636
Provider Enumeration Date:
10/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  57091 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 011092 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2239604 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 54-1549651 . This is a "PCR" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 54-1549651 . This is a "PHCS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 6731201 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1201718 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 265470 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 873734 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1732397 . This is a "FIRST HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 122251 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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