Basic Information
| Provider Information | |||||||||
| NPI: | 1720577992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEFELICE | ||||||||
| FirstName: | DOMINICK | ||||||||
| MiddleName: | SAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 CLINTON AVE S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146201448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852794800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 777 CLINTON AVE S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146201448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852794800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2018 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 309120 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.