Provider Demographics
NPI:1821001934
Name:DOMANSKI, MARK EDWARD (D C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:DOMANSKI
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-9596
Mailing Address - Country:US
Mailing Address - Phone:912-961-9200
Mailing Address - Fax:
Practice Address - Street 1:320 E MONTGOMERY XRD
Practice Address - Street 2:SUITE 30
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4963
Practice Address - Country:US
Practice Address - Phone:912-353-7611
Practice Address - Fax:912-353-7147
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005411111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCDMXMedicare ID - Type UnspecifiedMEDICARE #
GAU59202Medicare UPIN