Provider Demographics
NPI:1235275496
Name:ALTIERI, DOMINIC JOHN (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:JOHN
Last Name:ALTIERI
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:PO BOX 13477
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-0768
Mailing Address - Country:US
Mailing Address - Phone:631-952-5701
Mailing Address - Fax:631-952-5740
Practice Address - Street 1:2500 NESCONSET HWY BLDG 15A
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2554
Practice Address - Country:US
Practice Address - Phone:631-751-2900
Practice Address - Fax:631-751-2051
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165242-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01144930Medicaid
NY01144930Medicaid
NY0601RHMedicare PIN