Provider Demographics
NPI:1588764500
Name:DOMINICK CONDO, MD PA
Entity type:Organization
Organization Name:DOMINICK CONDO, MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CONDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-436-2800
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-0051
Mailing Address - Country:US
Mailing Address - Phone:201-436-2800
Mailing Address - Fax:201-436-9840
Practice Address - Street 1:622 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3821
Practice Address - Country:US
Practice Address - Phone:201-436-2800
Practice Address - Fax:201-436-9840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA041384207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1179004Medicaid
NJ1K6533OtherHEALTHNET
NJ4121298OtherCIGNA
NJ70970OtherAETNA
NJ8177OtherGHI
NJHP095OtherOXFORD
NJ8177OtherGHI
NJ=========OtherHORIZON
NJ8177OtherGHI
NJ528110Medicare ID - Type Unspecified