Provider Demographics
NPI:1811644982
Name:DOMAL, SEAN JOSEPH
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:JOSEPH
Last Name:DOMAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7031 SUMMER TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2668
Mailing Address - Country:US
Mailing Address - Phone:574-309-5311
Mailing Address - Fax:
Practice Address - Street 1:2280 INWOOD RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7321
Practice Address - Country:US
Practice Address - Phone:214-648-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program