Provider Demographics
NPI:1609087451
Name:DOMICIANO V. CAPITLY, M.D.
Entity Type:Organization
Organization Name:DOMICIANO V. CAPITLY, M.D.
Other - Org Name:PARK AVENUE PRIMARY MEDICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOMICIANO
Authorized Official - Middle Name:V
Authorized Official - Last Name:CAPITLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-561-3934
Mailing Address - Street 1:1907 PARK AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-5530
Mailing Address - Country:US
Mailing Address - Phone:908-561-3934
Mailing Address - Fax:908-561-6881
Practice Address - Street 1:1907 PARK AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-5530
Practice Address - Country:US
Practice Address - Phone:908-561-3934
Practice Address - Fax:908-561-6881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0722804Medicaid
NJ445861Medicare ID - Type Unspecified
NJ0722804Medicaid