Provider Demographics
NPI:1629155171
Name:GAZIANO, DOMINIC JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:JOSEPH
Last Name:GAZIANO
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 1:3100 MACCORKLE AVE SE
Mailing Address - Street 2:SUITE 404
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1223
Mailing Address - Country:US
Mailing Address - Phone:304-346-1811
Mailing Address - Fax:304-343-3086
Practice Address - Street 1:3100 MACCORKLE AVE SE
Practice Address - Street 2:SUITE 404
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1223
Practice Address - Country:US
Practice Address - Phone:304-346-1811
Practice Address - Fax:304-343-3086
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV08871174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6002854Medicaid
WV6002854Medicaid