Provider Demographics
NPI:1568451995
Name:DOMOSI, DENNIS
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:DOMOSI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 HIGH AVE
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-2407
Mailing Address - Country:US
Mailing Address - Phone:845-353-1441
Mailing Address - Fax:845-353-1987
Practice Address - Street 1:258 HIGH AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-2407
Practice Address - Country:US
Practice Address - Phone:845-353-1441
Practice Address - Fax:845-353-1987
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1533681174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000075204OtherGHI HMO #
NY153368OtherHIP #
NY363522OtherTACONIC IPA #
NY230544OtherWELLCARE #
NY4399282OtherAETNA PPO #
NY0203731OtherGHI PPO #
NYP3098499OtherOXFORD #
NY100004101OtherAFFINITY HEALTH PLAN #
NYDD3368OtherATLANTIS HEALTH PLAN #
NY00945253Medicaid
NY0888254OtherAETNA HMO #
NY675E41OtherEMPIRE BCBS #
NY153368OtherCONNECTICARE #
NY363522OtherMVP #
NY0D3068OtherHEALTHNET #
NY4399282OtherAETNA PPO #
NY36D911Medicare PIN