Provider Demographics
NPI:1275694242
Name:DOMENECH, LUIS F (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:F
Last Name:DOMENECH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21333 HAGGERTY RD.
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5514
Mailing Address - Country:US
Mailing Address - Phone:248-662-0250
Mailing Address - Fax:248-662-9845
Practice Address - Street 1:1385 EAST EMPIRE AVENUE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-2037
Practice Address - Country:US
Practice Address - Phone:800-979-9595
Practice Address - Fax:248-662-9845
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077232207Q00000X
PR9465208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
E66625Medicare UPIN
81557Medicare ID - Type Unspecified