Basic Information
| Provider Information | |||||||||
| NPI: | 1952613598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPORTELLI | ||||||||
| FirstName: | DOMENICK | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PHEASANT RUN | ||||||||
| Address2: | |||||||||
| City: | BOONTON TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070059036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738688328 | ||||||||
| FaxNumber: | 9733962575 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 POCONO RD | ||||||||
| Address2: | |||||||||
| City: | DENVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736256000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2010 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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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 | 2084P0800X | 25MB09258000 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.