Provider Demographics
NPI:1609936806
Name:DOMINGO, JOSELITO B (MD)
Entity Type:Individual
Prefix:
First Name:JOSELITO
Middle Name:B
Last Name:DOMINGO
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 1:59 KOCH AVE
Mailing Address - Street 2:
Mailing Address - City:MORRIS PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07950-4400
Mailing Address - Country:US
Mailing Address - Phone:973-588-5300
Mailing Address - Fax:
Practice Address - Street 1:59 KOCH AVE
Practice Address - Street 2:
Practice Address - City:MORRIS PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07950-4400
Practice Address - Country:US
Practice Address - Phone:973-538-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA060122002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ887864C2EOtherMEDICARE BILLING NO.
NJDO887864Medicare ID - Type Unspecified
NJG32802Medicare UPIN