Healthcare Provider Details

I. General information

NPI: 1932333093
Provider Name (Legal Business Name): DOMENICO VITERBO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 WASHINGTON AVE STE 101
ALBANY NY
12206-1056
US

IV. Provider business mailing address

111 CLOCK TOWER CMNS
BREWSTER NY
10509-4055
US

V. Phone/Fax

Practice location:
  • Phone: 518-438-4483
  • Fax:
Mailing address:
  • Phone: 845-592-4915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberQ3826
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number283724-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: