Provider Demographics
NPI:1033637459
Name:CUSUMANO, DOMINIC ANTHONY IV (PT)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:ANTHONY
Last Name:CUSUMANO
Suffix:IV
Gender:M
Credentials:PT
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Mailing Address - Street 1:1773 STAR BATT DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-3708
Mailing Address - Country:US
Mailing Address - Phone:248-601-9207
Mailing Address - Fax:248-650-8670
Practice Address - Street 1:48875 HAYES RD
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48315-4405
Practice Address - Country:US
Practice Address - Phone:586-532-9602
Practice Address - Fax:586-439-5380
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501018404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist