Provider Demographics
NPI:1548876667
Name:PACIULLO, DOMINIC A
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:A
Last Name:PACIULLO
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 1:178 WATERMELON HILL RD
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-4439
Mailing Address - Country:US
Mailing Address - Phone:718-597-8323
Mailing Address - Fax:
Practice Address - Street 1:777 WESTCHESTER AVE STE 101
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-3520
Practice Address - Country:US
Practice Address - Phone:646-302-3306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY537861041174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty