1609087451 NPI number — DOMICIANO V. CAPITLY, M.D.

Table of content: (NPI 1609087451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609087451 NPI number — DOMICIANO V. CAPITLY, M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOMICIANO V. CAPITLY, M.D.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PARK AVENUE PRIMARY MEDICAL
Provider Other Organization Name Type Code:
5
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:
1609087451
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1907 PARK AVE
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
SOUTH PLAINFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07080-5530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-561-3934
Provider Business Mailing Address Fax Number:
908-561-6881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1907 PARK AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
SOUTH PLAINFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07080-5530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-561-3934
Provider Business Practice Location Address Fax Number:
908-561-6881
Provider Enumeration Date:
05/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CAPITLY
Authorized Official First Name:
DOMICIANO
Authorized Official Middle Name:
V
Authorized Official Title or Position:
MEDICAL DOCTOR
Authorized Official Telephone Number:
908-561-3934

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0722804 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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