Provider Demographics
NPI:1245763846
Name:DOMINGUE, BERTHONY
Entity Type:Individual
Prefix:
First Name:BERTHONY
Middle Name:
Last Name:DOMINGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2669 FRIES MILL RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-3336
Mailing Address - Country:US
Mailing Address - Phone:973-860-8552
Mailing Address - Fax:
Practice Address - Street 1:2669 FRIES MILL RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-3336
Practice Address - Country:US
Practice Address - Phone:973-860-8552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347B00000XTransportation ServicesBus