Basic Information
| Provider Information | |||||||||
| NPI: | 1487681391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLETTA | ||||||||
| FirstName: | DOMENIC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 698 | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737400607 | ||||||||
| FaxNumber: | 9734220353 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 STONE HARBOR BOULEVARD | ||||||||
| Address2: | BURDETTE TOMLIN MEMORIAL HOSPITAL EMERGENCY DEPARTMENT | ||||||||
| City: | CAPE MAY COURT HOUSE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094632339 | ||||||||
| FaxNumber: | 6094632946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 08/04/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25MA04617200 | NJ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1435701 | 05 | NJ | MEDICAID |