Provider Demographics
NPI:1952059552
Name:AFFUSO, DOMINIC ROBERT
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:ROBERT
Last Name:AFFUSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31611 N 132ND DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-7958
Mailing Address - Country:US
Mailing Address - Phone:480-340-1750
Mailing Address - Fax:
Practice Address - Street 1:17300 N 88TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3501
Practice Address - Country:US
Practice Address - Phone:480-340-1750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-13
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5333225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist