Provider Demographics
NPI:1336250356
Name:SULFARO, DOMENIC F JR (PT, DPT, LATC)
Entity Type:Individual
Prefix:
First Name:DOMENIC
Middle Name:F
Last Name:SULFARO
Suffix:JR
Gender:M
Credentials:PT, DPT, LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1868
Mailing Address - Country:US
Mailing Address - Phone:781-331-9600
Mailing Address - Fax:781-335-1556
Practice Address - Street 1:541 MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1868
Practice Address - Country:US
Practice Address - Phone:781-331-9600
Practice Address - Fax:781-335-1556
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16543225100000X
MA6242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA626330OtherHARVARD PILGRIM
MA981075OtherNETWORK HEALTH
MA328820OtherCIGNA
MA470490OtherTUFTS
MA0329720Medicaid
MAY68210OtherBLUE CROSS
MA64029OtherAETNA
MAY69320Medicare ID - Type UnspecifiedMEDICARE