Provider Demographics
NPI:1649214404
Name:LOBRAICO, DOMINICK ANTHONY (DO)
Entity Type:Individual
Prefix:
First Name:DOMINICK
Middle Name:ANTHONY
Last Name:LOBRAICO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702-4205
Mailing Address - Country:US
Mailing Address - Phone:732-345-1887
Mailing Address - Fax:
Practice Address - Street 1:1019 BROADWAY
Practice Address - Street 2:
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1326
Practice Address - Country:US
Practice Address - Phone:732-229-6797
Practice Address - Fax:732-229-6893
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB56878174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6585108Medicare ID - Type Unspecified
NJ779909C8MMedicare ID - Type Unspecified
NJG07286Medicare UPIN