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: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11885 E 12 MILE RD STE 300A
WARREN MI
48093-3467
US

IV. Provider business mailing address

11885 E 12 MILE RD STE 300A
WARREN MI
48093-3467
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-7470
  • Fax: 586-573-0850
Mailing address:
  • Phone: 586-573-7470
  • Fax: 586-573-0850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: