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Dr. Dominick Detommaso
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NPI Number Detailed Information
Provider Information:
| Name: | Dr. Dominick Detommaso |
| Gender: | M |
| Provider License Number If Given: | 07000410A |
NPI Information:
| NPI: | 1013910041 |
| Entity Type (Individual or Organization): |
1-ind |
| Enumeration Date: | 5/23/2005 |
| Last Update Date: | 3/22/2016 |
Provider Business Mailing Address:
| Address: | 7601 W JEFFERSON BLVD Fort Wayne, IN 46804 |
| Phone Number: | 2604368686 |
| Fax Number: | 2604368585 |
Provider Business Practice Location Address:
| Address: | 7601 W JEFFERSON BLVD Fort Wayne, IN 46804 |
| Phone Number: | 2604368686 |
| Fax Number: | 2604368585 |
Provider Taxonomy:
| Primary: | 213E00000X |
| Secondary (if any): | 213ES0103X |
| State: | IN |
