1013910041 NPI number — DR. DOMINICK DETOMMASO D.P.M.

Table of content: DR. DOMINICK DETOMMASO D.P.M. (NPI 1013910041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013910041 NPI number — DR. DOMINICK DETOMMASO D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETOMMASO
Provider First Name:
DOMINICK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013910041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7601 W JEFFERSON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804-4133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-436-8686
Provider Business Mailing Address Fax Number:
260-436-8585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7601 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-4133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-436-8686
Provider Business Practice Location Address Fax Number:
260-436-8585
Provider Enumeration Date:
05/23/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  07000410A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X , with the licence number: 07000410A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100053980A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00000089407 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200021084 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".