Provider Demographics
NPI:1679351076
Name:PETRONICO, DOMINICK (DPT)
Entity type:Individual
Prefix:MR
First Name:DOMINICK
Middle Name:
Last Name:PETRONICO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 ROUTE 34
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-2132
Mailing Address - Country:US
Mailing Address - Phone:732-320-6285
Mailing Address - Fax:732-374-9864
Practice Address - Street 1:144 ROUTE 34
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-2132
Practice Address - Country:US
Practice Address - Phone:732-320-6285
Practice Address - Fax:732-374-9864
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ402A02210700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist