Provider Demographics
NPI:1124337373
Name:DOUGLASS T. DOMOTO, M.D., J.D., P.C.
Entity type:Organization
Organization Name:DOUGLASS T. DOMOTO, M.D., J.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLASS
Authorized Official - Middle Name:TAKASHI
Authorized Official - Last Name:DOMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD, JD
Authorized Official - Phone:314-535-3720
Mailing Address - Street 1:2606 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2502
Mailing Address - Country:US
Mailing Address - Phone:314-535-3720
Mailing Address - Fax:314-535-7391
Practice Address - Street 1:2606 CLARK AVE
Practice Address - Street 2:AVE
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2502
Practice Address - Country:US
Practice Address - Phone:314-535-3720
Practice Address - Fax:314-535-7391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6C21207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA10340Medicare UPIN