Healthcare Provider Details

I. General information

NPI: 1649496092
Provider Name (Legal Business Name): DOMINICK ADDARIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 1ST AVE
SAN DIEGO CA
92103-5816
US

IV. Provider business mailing address

3010 1ST AVE
SAN DIEGO CA
92103-5816
US

V. Phone/Fax

Practice location:
  • Phone: 619-295-2189
  • Fax: 619-295-2362
Mailing address:
  • Phone: 619-295-2189
  • Fax: 619-295-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberG21620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: