Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 036119758 | IL |
NPI | 1154454635 |
---|---|
Provider Name | Dr. Benjamin Domb |
First Address | Des Plaines, IL 60018-2748 |
Second Address | Des Plaines, IL 60018-2748 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/03/2007 |
Last Update Date | 30/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036119758 | (05) | IL |
1154454635 | (02) | IL |