Healthcare Provider Details

I. General information

NPI: 1013954585
Provider Name (Legal Business Name): DOMIAN KANDAH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 E 12 MILE RD
WARREN MI
48093-3472
US

IV. Provider business mailing address

307 S EVERGREEN AVE
WOODBURY NJ
08096-2739
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-5059
  • Fax:
Mailing address:
  • Phone: 856-686-4308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number008716
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101008716
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: