Provider Demographics
NPI:1588764724
Name:DOMOTO, DOUGLASS TAKASHI (MD, JD)
Entity type:Individual
Prefix:DR
First Name:DOUGLASS
Middle Name:TAKASHI
Last Name:DOMOTO
Suffix:
Gender:M
Credentials:MD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:324-525-7391
Practice Address - Street 1:2606 CLARK AVE
Practice Address - Street 2:
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:324-525-7391
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6C21207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA10340Medicare UPIN
MO7575Medicare ID - Type Unspecified