Provider Demographics
NPI:1487681391
Name:COLETTA, DOMENIC (MD)
Entity Type:Individual
Prefix:
First Name:DOMENIC
Middle Name:
Last Name:COLETTA
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:PO BOX 698
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039
Mailing Address - Country:US
Mailing Address - Phone:973-740-0607
Mailing Address - Fax:973-422-0353
Practice Address - Street 1:2 STONE HARBOR BOULEVARD
Practice Address - Street 2:BURDETTE TOMLIN MEMORIAL HOSPITAL EMERGENCY DEPARTMENT
Practice Address - City:CAPE MAY COURT HOUSE
Practice Address - State:NJ
Practice Address - Zip Code:08210
Practice Address - Country:US
Practice Address - Phone:609-463-2339
Practice Address - Fax:609-463-2946
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04617200207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1435701Medicaid
NJ1435701Medicaid
NJ583631Medicare ID - Type Unspecified