Provider Demographics
NPI:1801834429
Name:DOMINGO, MARIE ANNETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:ANNETTE
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1405
Mailing Address - Country:US
Mailing Address - Phone:201-956-9364
Mailing Address - Fax:
Practice Address - Street 1:172 WASHINGTON VALLEY RD STE 5
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-7178
Practice Address - Country:US
Practice Address - Phone:201-956-9364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA07159300207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG59659Medicare UPIN