Provider Demographics
NPI:1720577992
Name:DEFELICE, DOMINICK SAM (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINICK
Middle Name:SAM
Last Name:DEFELICE
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:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-763-5522
Mailing Address - Fax:910-763-0413
Practice Address - Street 1:2523 DELANEY AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6003
Practice Address - Country:US
Practice Address - Phone:910-763-5522
Practice Address - Fax:910-763-0413
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2023-00901207Q00000X
NY309120207ZN0500X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program