Provider Demographics
NPI:1043327935
Name:LUIS POMODORO M D PC
Entity Type:Organization
Organization Name:LUIS POMODORO M D PC
Other - Org Name:LUIS POMODORO M D P C
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:POMODORO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-425-5320
Mailing Address - Street 1:15645 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-2851
Mailing Address - Country:US
Mailing Address - Phone:734-425-5320
Mailing Address - Fax:734-425-6212
Practice Address - Street 1:15645 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-2851
Practice Address - Country:US
Practice Address - Phone:734-425-5320
Practice Address - Fax:734-425-6212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010377062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI118156OtherCARE CHOICES
MI2608203502OtherBLUE CROSS BLUE SHIELD
MI118156OtherPREFERRED CHOICES
MI036223OtherVALUE OPTIONS
MI1958828Medicaid
MI1958828Medicaid
MI0P49400Medicare PIN