1144209552 NPI number — RICHARD TODD DOMBROSKI DO

Table of content: RICHARD TODD DOMBROSKI DO (NPI 1144209552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144209552 NPI number — RICHARD TODD DOMBROSKI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMBROSKI
Provider First Name:
RICHARD
Provider Middle Name:
TODD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOMBROSKI
Provider Other First Name:
TODD
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1144209552
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8332 WHIPPOORWILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76123-1994
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-412-0877
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6913 CAMP BOWIE BLVD STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76116-7164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-367-9289
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2006

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: 207Q00000X , with the licence number:  Q3358 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS0010X , with the licence number: Q3358 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 204D00000X , with the licence number: Q3358 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8FA812 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01609114 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 344044804 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8FA814 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 344044801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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