Provider Demographics
NPI:1891919585
Name:DEDOMENICO, NOREEN (OPTICIAN)
Entity Type:Individual
Prefix:MRS
First Name:NOREEN
Middle Name:
Last Name:DEDOMENICO
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:MRS
Other - First Name:NOREEN
Other - Middle Name:
Other - Last Name:DEDOMENICO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OPTICIAN
Mailing Address - Street 1:58 STANLEY RD
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-3238
Mailing Address - Country:US
Mailing Address - Phone:203-288-0409
Mailing Address - Fax:
Practice Address - Street 1:904 WHALLEY AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515-1700
Practice Address - Country:US
Practice Address - Phone:203-397-1928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTLO702156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0521380001OtherMEDICARE
CT100000702CT01OtherBLUE CROSS
CT0521380001Medicare NSC