Provider Demographics
NPI:1124077474
Name:DOMIS, MICHAEL EUGENE (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EUGENE
Last Name:DOMIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5509 GRAND BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-3836
Mailing Address - Country:US
Mailing Address - Phone:727-572-5449
Mailing Address - Fax:727-844-5425
Practice Address - Street 1:18203 SANDY POINTE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647
Practice Address - Country:US
Practice Address - Phone:727-804-3668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2713213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390456300Medicaid
FL390456300Medicaid
FL65560DMedicare ID - Type UnspecifiedMEDICARE IDENTIFIER