Provider Demographics
NPI:1942380902
Name:DOMENICO, LOUIS JR (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:DOMENICO
Suffix:JR
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:PO BOX 416147
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6147
Mailing Address - Country:US
Mailing Address - Phone:610-644-8900
Mailing Address - Fax:484-924-0053
Practice Address - Street 1:2412-14 WEST PASSYUNK AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4114
Practice Address - Country:US
Practice Address - Phone:215-462-2100
Practice Address - Fax:215-462-3100
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4265322085R0202X, 2085R0204X
NJ25MA083285002085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0157562Medicaid
NJP00823218OtherRAILROAD MEDICARE
PA1017778250003Medicaid
PA1017778250003Medicaid
NJ0157562Medicaid
PA107322RS8Medicare PIN