1205018470 NPI number — DAVID J DOMENICHINI MD, PC

Table of content: (NPI 1205018470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205018470 NPI number — DAVID J DOMENICHINI MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID J DOMENICHINI MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1205018470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 COTTAGE GROVE RD STE B220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06002-3077
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-561-1007
Provider Business Mailing Address Fax Number:
860-561-1222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 COTTAGE GROVE RD STE B220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06002-3077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-561-1007
Provider Business Practice Location Address Fax Number:
860-561-1222
Provider Enumeration Date:
11/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DOMENICHINI
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
860-561-1007

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  032306 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 032306 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X , with the licence number: 032306 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C03887 . This is a "MEDICARE GROUP" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 50DOMENICCT01 . This is a "ANTHEM BLUE CROSS/ BLUE SHIELD GROUP" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 500000218 . This is a "MEDICAID GROUP" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 500000332 . This is a "MEDICAID APRN GROUP" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: DH2482 . This is a "MEDICARE RAILROAD GROUP" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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