Provider Demographics
NPI:1982776928
Name:DOMINIK, SUSAN (DC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:DOMINIK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 WOODBOURNE RD
Mailing Address - Street 2:SUITE 401A
Mailing Address - City:LEVITTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19057-1500
Mailing Address - Country:US
Mailing Address - Phone:215-945-1100
Mailing Address - Fax:215-945-5086
Practice Address - Street 1:1609 WOODBOURNE RD
Practice Address - Street 2:SUITE 401A
Practice Address - City:LEVITTOWN
Practice Address - State:PA
Practice Address - Zip Code:19057-1500
Practice Address - Country:US
Practice Address - Phone:215-945-1100
Practice Address - Fax:215-945-5086
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003470L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011499230004Medicaid
PA0011499230004Medicaid