Provider Demographics
NPI:1205412483
Name:DEDOMENICO, GREGG EDWARD (PT, DPT, MS, ATC)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:EDWARD
Last Name:DEDOMENICO
Suffix:
Gender:M
Credentials:PT, DPT, MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CARTAGENA DR
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-7005
Mailing Address - Country:US
Mailing Address - Phone:347-609-3038
Mailing Address - Fax:
Practice Address - Street 1:208 N DUPONT BLVD
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1511
Practice Address - Country:US
Practice Address - Phone:302-539-8389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0014325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist