Provider Demographics
NPI:1609180694
Name:DOMINO, DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:DOMINO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:27351 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3487
Mailing Address - Country:US
Mailing Address - Phone:248-967-7795
Mailing Address - Fax:248-967-7794
Practice Address - Street 1:27351 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3487
Practice Address - Country:US
Practice Address - Phone:248-967-7795
Practice Address - Fax:248-967-7794
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101018774208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery