Provider Demographics
NPI:1003135500
Name:DOMINELLO, MICHAEL MATTHEW (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MATTHEW
Last Name:DOMINELLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400 - CREDENTIALING DEPARTMENT
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:800-527-6266
Mailing Address - Fax:313-576-9640
Practice Address - Street 1:4100 JOHN R
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:800-527-6266
Practice Address - Fax:313-576-9640
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI51010193882085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology