Provider Demographics
NPI:1518967520
Name:DOMENICO, ANTHONY (DPM)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:DOMENICO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13B BIRCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:NJ
Mailing Address - Zip Code:08759-1732
Mailing Address - Country:US
Mailing Address - Phone:732-350-3763
Mailing Address - Fax:
Practice Address - Street 1:56 SCHOOLHOUSE RD
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:NJ
Practice Address - Zip Code:08759-3052
Practice Address - Country:US
Practice Address - Phone:732-716-1300
Practice Address - Fax:732-716-1290
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00084900213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1720503Medicaid
NJ1720503Medicaid
T45557Medicare UPIN