Provider Demographics
NPI:1235119215
Name:DOMJAN, DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:DOMJAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6738 STATE HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63736-8238
Mailing Address - Country:US
Mailing Address - Phone:573-313-2500
Mailing Address - Fax:573-313-2505
Practice Address - Street 1:200 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4403
Practice Address - Country:US
Practice Address - Phone:573-472-1770
Practice Address - Fax:573-472-4050
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO118085171100000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204706030Medicaid
MO1235119215Medicaid
MO950432446Medicare PIN
MO106260006Medicare PIN