Basic Information
Provider Information | |||||||||
NPI: | 1952539280 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOMZALSKI | ||||||||
FirstName: | JEROME | ||||||||
MiddleName: | TAYMON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 19020 33RD AVE W STE 210 | ||||||||
Address2: |   | ||||||||
City: | LYNNWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 980364748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4255631500 | ||||||||
FaxNumber: | 4255631374 | ||||||||
Practice Location | |||||||||
Address1: | 19020 33RD AVE W STE 210 | ||||||||
Address2: |   | ||||||||
City: | LYNNWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 980364748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4255631500 | ||||||||
FaxNumber: | 4255631501 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2009 | ||||||||
LastUpdateDate: | 08/26/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD185931 | OR | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD60808674 | WA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | M-14669 | ID | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 0384883 | 01 | WA | LNI UAOM | OTHER | 0408173 | 01 | WA | LNI EVERGREEN RADIA | OTHER | 0384879 | 01 | WA | LNI TRA-MINW, PS KING COUNTY | OTHER | 0408166 | 01 | WA | LNI RADIA REST OF WA | OTHER | 0384868 | 01 | WA | LNI TRA-MINW, PS REST OF WA COUNTIES | OTHER | 0384886 | 01 | WA | LNI DINW | OTHER | 2094399 | 05 | WA |   | MEDICAID | 0408168 | 01 | WA | LNI RADIA KING COUNTY | OTHER | 0408171 | 01 | WA | LNI SWEDISH RADIA EDMONDS | OTHER | 0408176 | 01 | WA | LNI SEATTLE RADIOLOGY | OTHER | 0408174 | 01 | WA | LNI SOUTH SOUND RADIOLOGY | OTHER |