Provider Demographics
NPI:1164982328
Name:MISIAK, DOMINIC ERNEST (DO)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:ERNEST
Last Name:MISIAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44725 GRAND RIVER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1024
Mailing Address - Country:US
Mailing Address - Phone:517-882-3732
Mailing Address - Fax:517-882-3633
Practice Address - Street 1:44725 GRAND RIVER AVE STE 104
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1024
Practice Address - Country:US
Practice Address - Phone:517-882-3732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-23
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010261262084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry