Provider Demographics
NPI:1538251517
Name:DIDOMENICO, ROBERT J (DC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:DIDOMENICO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W NORTH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1174
Mailing Address - Country:US
Mailing Address - Phone:312-664-9060
Mailing Address - Fax:312-664-9181
Practice Address - Street 1:711 W NORTH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1174
Practice Address - Country:US
Practice Address - Phone:312-664-9060
Practice Address - Fax:312-664-9181
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01606734OtherBLUE CROSS BLUE SHIELD
IL01606734OtherBLUE CROSS BLUE SHIELD
IL201215Medicare ID - Type Unspecified