Provider Demographics
NPI:1730113895
Name:POSILLICO, DOMINIC J (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:J
Last Name:POSILLICO
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 1:475 MAIN ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-3570
Mailing Address - Country:US
Mailing Address - Phone:516-753-1155
Mailing Address - Fax:
Practice Address - Street 1:475 MAIN ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3570
Practice Address - Country:US
Practice Address - Phone:516-753-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164179207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD91936Medicare UPIN
NY04F231Medicare ID - Type Unspecified