Provider Demographics
NPI:1396130613
Name:DOMINA, MICHAEL GLENN (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GLENN
Last Name:DOMINA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 SOUTH TULANE AVENUE
Mailing Address - Street 2:5303
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:740 MIDDLE CREEK RD STE 200
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-5056
Practice Address - Country:US
Practice Address - Phone:865-908-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO213625207V00000X
MEDO3503207V00000X
MELT22012207V00000X
NE1630207V00000X
TN5095207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ083566Medicaid