Provider Demographics
NPI:1235303801
Name:TRIVISONNO, DOMINICK PETER (MD)
Entity Type:Individual
Prefix:
First Name:DOMINICK
Middle Name:PETER
Last Name:TRIVISONNO
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 1119
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:MT
Mailing Address - Zip Code:59313-1119
Mailing Address - Country:US
Mailing Address - Phone:406-778-2833
Mailing Address - Fax:406-778-5131
Practice Address - Street 1:202 SOUTH 4TH STREET WEST
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:MT
Practice Address - Zip Code:59313-1119
Practice Address - Country:US
Practice Address - Phone:406-778-2833
Practice Address - Fax:406-778-5131
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173465208D00000X
MT11857208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice