Provider Demographics
NPI:1679535934
Name:DOMINIK, JOSEPH D (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:D
Last Name:DOMINIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8840 COMMERCE PARK PL STE E
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 OAK ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-3350
Practice Address - Country:US
Practice Address - Phone:765-656-3970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028123A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100083680Medicaid
E03923Medicare UPIN
IN220620UUUMedicare PIN
IN100083680Medicaid
INM400070380Medicare PIN