Healthcare Provider Details

I. General information

NPI: 1952097065
Provider Name (Legal Business Name): IAN J DOMINGUEZ DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE RD
TROY MI
48085-1117
US

IV. Provider business mailing address

1827 OAKSHIRE AVE
BERKLEY MI
48072-1285
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number5101029481
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: