Provider Demographics
NPI:1639262843
Name:DOMINO, STEVEN E (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:E
Last Name:DOMINO
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 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:475 MARKET PLACE
Practice Address - Street 2:BLDG ONE
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1649
Practice Address - Country:US
Practice Address - Phone:734-763-4323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056598207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3386847Medicaid
MI3386847Medicaid
MI0H16063090Medicare ID - Type Unspecified