Provider Demographics
NPI:1386287134
Name:DOMINIC, ROSHAN
Entity type:Individual
Prefix:
First Name:ROSHAN
Middle Name:
Last Name:DOMINIC
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 1:3251 N DEERFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-1909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2923 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOHEGAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:10547-1836
Practice Address - Country:US
Practice Address - Phone:516-606-2845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist