Provider Demographics
NPI:1720362635
Name:SIA, DOMINIC CHIONGLO (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:CHIONGLO
Last Name:SIA
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 1:777 S WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037-2029
Mailing Address - Country:US
Mailing Address - Phone:609-567-0608
Mailing Address - Fax:
Practice Address - Street 1:777 S WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:HAMMONTON
Practice Address - State:NJ
Practice Address - Zip Code:08037-2029
Practice Address - Country:US
Practice Address - Phone:609-567-0608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08987000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics