Provider Demographics
NPI:1912465980
Name:ELVITA GENELUS-DOMINIQUE, D.O, F.A.C.S, P.C
Entity Type:Organization
Organization Name:ELVITA GENELUS-DOMINIQUE, D.O, F.A.C.S, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELVITA
Authorized Official - Middle Name:
Authorized Official - Last Name:GENELUS-DOMINIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-721-5168
Mailing Address - Street 1:628 LENORE LN
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-4526
Mailing Address - Country:US
Mailing Address - Phone:516-721-5168
Mailing Address - Fax:
Practice Address - Street 1:5850 CATALPA AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5028
Practice Address - Country:US
Practice Address - Phone:718-821-1910
Practice Address - Fax:718-821-1125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03244057Medicaid