Provider Demographics
NPI:1487630877
Name:VICEDOMINI, JOHN P (PHD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:P
Last Name:VICEDOMINI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:P
Other - Last Name:VICEDOMINI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD PLLC
Mailing Address - Street 1:1286 SHAW PL
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1747
Mailing Address - Country:US
Mailing Address - Phone:516-221-2032
Mailing Address - Fax:
Practice Address - Street 1:1286 SHAW PL
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1747
Practice Address - Country:US
Practice Address - Phone:516-221-2032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0129651103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01767748Medicaid
NYV38971Medicare ID - Type Unspecified