Basic Information
| Provider Information | |||||||||
| NPI: | 1013912948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMESCEK | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076501300 | ||||||||
| FaxNumber: | 4076501307 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076501300 | ||||||||
| FaxNumber: | 4076501307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 11/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME57239 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | ME57239 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 063394100 | 05 | FL | MEDICAID | ME57239 | 01 | FL | MEDICAL LICENSE | OTHER |