Provider Demographics
NPI:1457327975
Name:MARIANO, DOMENIC L (DO)
Entity Type:Individual
Prefix:
First Name:DOMENIC
Middle Name:L
Last Name:MARIANO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028
Mailing Address - Country:US
Mailing Address - Phone:973-743-1121
Mailing Address - Fax:973-743-2627
Practice Address - Street 1:946 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028
Practice Address - Country:US
Practice Address - Phone:973-743-1121
Practice Address - Fax:973-743-2627
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB05816800207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7338201Medicaid
NJ044991Medicare PIN
F38661Medicare UPIN