Provider Demographics
NPI:1770615486
Name:DOMINGO, DAVID BUCAO (NP)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:BUCAO
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 VETERANS MEMORIAL HWY.
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779
Mailing Address - Country:US
Mailing Address - Phone:631-676-7656
Mailing Address - Fax:631-676-7648
Practice Address - Street 1:3505 VETERANS MEMORIAL HWY.
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779
Practice Address - Country:US
Practice Address - Phone:631-676-7656
Practice Address - Fax:631-676-7648
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303626363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02662297Medicaid
NY0818G1Medicare ID - Type Unspecified
NY02662297Medicaid