Provider Demographics
NPI:1790473940
Name:DOMINGO, MARC (PTA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 LITTLE EAST NECK RD
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-2411
Mailing Address - Country:US
Mailing Address - Phone:631-560-4548
Mailing Address - Fax:
Practice Address - Street 1:1026 LITTLE EAST NECK RD
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-2411
Practice Address - Country:US
Practice Address - Phone:631-560-4548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013504208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation