Provider Demographics
NPI:1821160276
Name:COMMODARO, DOMINICK A (DO)
Entity Type:Individual
Prefix:
First Name:DOMINICK
Middle Name:A
Last Name:COMMODARO
Suffix:
Gender:M
Credentials:DO
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 8500-6335
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:215-807-8000
Mailing Address - Fax:215-807-8235
Practice Address - Street 1:2807 BRISTOL PIKE
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-5362
Practice Address - Country:US
Practice Address - Phone:215-639-1281
Practice Address - Fax:215-639-3016
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005617L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010424620003Medicaid
PA0010424620004Medicaid
PA121502OtherHIGHMARK BLUE SHIELD
PA93539OtherAETNA HMO
PA0010424620001Medicaid
PA0010424620005Medicaid
PA30041893OtherKEYSTONE MERCY
PA37957OtherHEALTH PARTNERS
PA4076113OtherAETNA PPO
PA121502OtherPERSONAL CHOICE
PA121502OtherHIGHMARK BLUE SHIELD
PABR687657Medicare ID - Type Unspecified