Provider Demographics
NPI:1114019692
Name:CONDO, DOMINICK (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINICK
Middle Name:
Last Name:CONDO
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 1:622 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3821
Mailing Address - Country:US
Mailing Address - Phone:201-436-2800
Mailing Address - Fax:201-436-9840
Practice Address - Street 1:622 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3821
Practice Address - Country:US
Practice Address - Phone:201-436-2800
Practice Address - Fax:201-436-9840
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA041384207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ196166B0KMedicare ID - Type Unspecified
NJD07215Medicare UPIN