1205412483 NPI number — GREGG EDWARD DEDOMENICO PT, DPT, MS, ATC

Table of content: MARI LOERA (NPI 1891196754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205412483 NPI number — GREGG EDWARD DEDOMENICO PT, DPT, MS, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEDOMENICO
Provider First Name:
GREGG
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, MS, ATC
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:
1205412483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 CARTAGENA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRICK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08723-7005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-609-3038
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 N DUPONT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19977-1511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-539-8389
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/19/2021

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: 225100000X , with the licence number:  J1-0014325 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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