Provider Demographics
NPI:1831221357
Name:DIDOMENICO, LINDA M (DPM)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:M
Last Name:DIDOMENICO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1164 ALLIANCE RD NW
Mailing Address - Street 2:
Mailing Address - City:MINERVA
Mailing Address - State:OH
Mailing Address - Zip Code:44657-8736
Mailing Address - Country:US
Mailing Address - Phone:330-868-4599
Mailing Address - Fax:330-868-1379
Practice Address - Street 1:1164 ALLIANCE RD NW
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-8736
Practice Address - Country:US
Practice Address - Phone:330-868-4599
Practice Address - Fax:330-868-1379
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003119213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2219889Medicaid
OHDI4033871Medicare ID - Type Unspecified
OH2219889Medicaid