Basic Information
| Provider Information | |||||||||
| NPI: | 1386662872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIMINO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 536 | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080430536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566696050 | ||||||||
| FaxNumber: | 8566510794 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 IRONBRIDGE RD | ||||||||
| Address2: | STE 10 | ||||||||
| City: | FREEHOLD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7324312999 | ||||||||
| FaxNumber: | 7324312993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/28/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 60657 | NJ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | P00975975 | 01 | NJ | RAILROAD MEDICARE PTAN | OTHER | 6273408 | 05 | NJ | MEDICAID |