Provider Demographics
NPI:1902896889
Name:DOMINGO, CONNIE D (MD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:D
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 674
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-0674
Mailing Address - Country:US
Mailing Address - Phone:856-489-4520
Mailing Address - Fax:856-983-1065
Practice Address - Street 1:92 BRICK RD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2177
Practice Address - Country:US
Practice Address - Phone:856-489-4520
Practice Address - Fax:856-983-1065
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA063764002081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ313034Medicare PIN