Provider Demographics
NPI:1598753642
Name:CO, DOMINADOR (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINADOR
Middle Name:
Last Name:CO
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 1:401 ROUTE 73 N
Mailing Address - Street 2:40 LAKE CENTER DRIVE, SUITE 201A
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3425
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0346
Practice Address - Street 1:175 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NJ
Practice Address - Zip Code:08060-2038
Practice Address - Country:US
Practice Address - Phone:609-914-6180
Practice Address - Fax:609-914-6182
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04218400208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0642509Medicaid
NJ642270YBAWMedicare PIN
NJ642270R63Medicare ID - Type Unspecified
NJD19365Medicare UPIN