MEDICARE: DR. CONNIE D DOMINGO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081P0010X	Pediatric Rehabilitation Medicine Physician	MD2026-0032	NM
2	2081P0010X	Pediatric Rehabilitation Medicine Physician	25MA06376400	NJ

General Provider Information

NPI Number	:	1902896889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONNIE D DOMINGO MD

Provider Business Mailing Address
First Line	:	PO BOX 674
Second Line	:
City	:	MARLTON
State	:	NJ
Zip	:	08053-0674
Country	:	US
Telephone Number	:	856-489-4520
Fax Number	:	856-983-1065

Provider Business Practice Location Address
First Line	:	92 BRICK RD
Second Line	:	3RD FLOOR
City	:	MARLTON
State	:	NJ
Zip	:	08053-2177
Country	:	US
Telephone Number	:	856-489-4520
Fax Number	:	856-983-1065

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	01/21/2026

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Directions to “ DR. CONNIE D DOMINGO MD” Practice Location

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