Provider Demographics
NPI:1487628467
Name:MAIELLO, DOMINIC JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:JOSEPH
Last Name:MAIELLO
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 1:3 WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-1824
Mailing Address - Country:US
Mailing Address - Phone:201-798-2900
Mailing Address - Fax:201-798-3582
Practice Address - Street 1:3 WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-1824
Practice Address - Country:US
Practice Address - Phone:201-798-2900
Practice Address - Fax:201-798-3582
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA40942207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3284808Medicaid
NJ3284808Medicaid
C54632Medicare UPIN