Provider Demographics
NPI:1366423022
Name:DOMKOWSKI, PATRICK W (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:W
Last Name:DOMKOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14430 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3235
Mailing Address - Country:US
Mailing Address - Phone:772-581-8003
Mailing Address - Fax:772-581-8005
Practice Address - Street 1:14430 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3235
Practice Address - Country:US
Practice Address - Phone:772-581-8003
Practice Address - Fax:772-581-8005
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89469208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL239538OtherWELLCARE
FL3456730OtherAETNA
FL7801535OtherAETNA
FL6039513001OtherCIGNA
FL37840OtherBLUE CROSS BLUE SHIELD
FLP00217825OtherRAILROAD MEDICARE
FL122937200Medicaid
FL269280500Medicaid
FL269280500Medicaid