Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 0101240512 | VA |
NPI | 1083773006 |
---|---|
Provider Name | Martha O Dommisse |
First Address | Midlothian, VA 23114-4684 |
Second Address | Richmond, VA 23249-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2006 |
Last Update Date | 22/02/2011 |