Provider Demographics
NPI:1649228065
Name:EBOLI, DOMINICK J (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINICK
Middle Name:J
Last Name:EBOLI
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 1:832 BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08638-3847
Mailing Address - Country:US
Mailing Address - Phone:609-396-2600
Mailing Address - Fax:609-396-3600
Practice Address - Street 1:832 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08638-3847
Practice Address - Country:US
Practice Address - Phone:609-396-2600
Practice Address - Fax:609-396-3600
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06577700208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8398003Medicaid
H17042Medicare UPIN
NJ8398003Medicaid