Healthcare Provider Details

I. General information

NPI: 1306368527
Provider Name (Legal Business Name): DOMINIC ANTONIO ATIYEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 W MAPLE RD STE 100
CLAWSON MI
48017-1000
US

IV. Provider business mailing address

909 W MAPLE RD STE 100
CLAWSON MI
48017-1000
US

V. Phone/Fax

Practice location:
  • Phone: 248-435-2028
  • Fax: 833-479-2061
Mailing address:
  • Phone: 248-435-2028
  • Fax: 833-479-2061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301113327
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: