MEDICARE: DOMINICK MICHAEL MARTINICO

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1952006470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINICK MICHAEL MARTINICO

Provider Business Mailing Address
First Line	:	7729 W WESTWOOD DR
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-1804
Country	:	US
Telephone Number	:	708-280-7811
Fax Number	:

Provider Business Practice Location Address
First Line	:	7729 W WESTWOOD DR
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-1804
Country	:	US
Telephone Number	:	708-280-7811
Fax Number	:

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

Provider Enumeration Date	:	04/03/2023
Last Update Date	:	04/03/2023

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Directions to “ DOMINICK MICHAEL MARTINICO ” Practice Location

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