Provider Demographics
NPI:1548500275
Name:OLIVO, DOMINIC FRANK
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:FRANK
Last Name:OLIVO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 OLD BROOKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-3604
Mailing Address - Country:US
Mailing Address - Phone:973-945-5282
Mailing Address - Fax:
Practice Address - Street 1:30 OLD BROOKSIDE RD
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-3604
Practice Address - Country:US
Practice Address - Phone:973-945-5282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-16
Last Update Date:2013-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01442500225100000X
NY034959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist