Provider Demographics
NPI:1386918100
Name:AFFINITY MEDICAL PC
Entity type:Organization
Organization Name:AFFINITY MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMNICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-758-4100
Mailing Address - Street 1:8635 21ST AVE
Mailing Address - Street 2:1A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-4049
Mailing Address - Country:US
Mailing Address - Phone:718-758-4100
Mailing Address - Fax:
Practice Address - Street 1:8635 21ST AVE
Practice Address - Street 2:1A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-4049
Practice Address - Country:US
Practice Address - Phone:718-758-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217873207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY217873OtherLISCENCE