Provider Demographics
NPI:1053884320
Name:DOMB, MARC
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:DOMB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2351 SW MARTIN HWY
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-3222
Mailing Address - Country:US
Mailing Address - Phone:772-324-9337
Mailing Address - Fax:772-342-9347
Practice Address - Street 1:2351 SW MARTIN HWY
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3222
Practice Address - Country:US
Practice Address - Phone:723-249-3377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT17918225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT17918OtherPT LICENSE