MEDICARE: DR. ANTHONY DOMENICO DPM

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	213E00000X	Podiatrist	25MD00084900	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518967520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANTHONY DOMENICO DPM

Provider Business Mailing Address
First Line	:	13B BIRCHWOOD DR
Second Line	:
City	:	WHITING
State	:	NJ
Zip	:	08759-1732
Country	:	US
Telephone Number	:	732-350-3763
Fax Number	:

Provider Business Practice Location Address
First Line	:	56 SCHOOLHOUSE RD
Second Line	:
City	:	WHITING
State	:	NJ
Zip	:	08759-3052
Country	:	US
Telephone Number	:	732-716-1300
Fax Number	:	732-716-1290

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

Provider Enumeration Date	:	08/01/2005
Last Update Date	:	07/08/2007

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