Provider Demographics
NPI:1437265584
Name:ACQUARO, DOMINICK (MD)
Entity Type:Individual
Prefix:
First Name:DOMINICK
Middle Name:
Last Name:ACQUARO
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 1:7806 W JEFFERSON BLVD BLDG 2
Mailing Address - Street 2:STE. #C
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4179
Mailing Address - Country:US
Mailing Address - Phone:260-459-0087
Mailing Address - Fax:260-969-8514
Practice Address - Street 1:7806 W JEFFERSON BLVD BLDG 2
Practice Address - Street 2:STE. #C
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4179
Practice Address - Country:US
Practice Address - Phone:260-459-0087
Practice Address - Fax:260-969-8514
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037315207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000078561OtherANTHEM
INE03682Medicare UPIN
IN136280Medicare ID - Type UnspecifiedMEDICARE