Provider Demographics
NPI:1184821860
Name:DR. SALVATORE DIDOMENICO DCPA
Entity Type:Organization
Organization Name:DR. SALVATORE DIDOMENICO DCPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SALVATORE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIDOMENICO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-365-4506
Mailing Address - Street 1:7466 EDENMORE ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-7900
Mailing Address - Country:US
Mailing Address - Phone:727-365-4506
Mailing Address - Fax:
Practice Address - Street 1:7466 EDENMORE STREET
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202
Practice Address - Country:US
Practice Address - Phone:727-365-4506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0007562261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381824100Medicaid
FL55940Medicare ID - Type Unspecified