1861478216 NPI number — MR. GERALD F DOMINICK PA C

Table of content: MR. GERALD F DOMINICK PA C (NPI 1861478216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861478216 NPI number — MR. GERALD F DOMINICK PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMINICK
Provider First Name:
GERALD
Provider Middle Name:
F
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA C
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:
1861478216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 41115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23541-1115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-466-0089
Provider Business Mailing Address Fax Number:
757-466-8017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5544 GREENWICH RD
Provider Second Line Business Practice Location Address:
STE.200
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23462-6563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-466-0089
Provider Business Practice Location Address Fax Number:
757-466-8017
Provider Enumeration Date:
12/19/2005

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: 363A00000X , with the licence number:  PA219354 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0110000927 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 139178 . This is a "BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 10005129P . This is a "SENTARA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 10005129P . This is a "OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00318486 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1861478216 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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