Basic Information
| Provider Information | |||||||||
| NPI: | 1114962388 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMOWICZ | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 413 86TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112094707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189219721 | ||||||||
| FaxNumber: | 7189219349 | ||||||||
| Practice Location | |||||||||
| Address1: | 4013 AVENUE U | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112345117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186924100 | ||||||||
| FaxNumber: | 7186920089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225100000X | 022450 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2432818 | 01 | NY | UNITED HEALTH CARE | OTHER |