Provider Demographics
NPI:1659808053
Name:MAMMO, GEORGE DOMINIC (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:DOMINIC
Last Name:MAMMO
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3790
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-3790
Mailing Address - Country:US
Mailing Address - Phone:483-364-0002
Mailing Address - Fax:
Practice Address - Street 1:4420 E DAVISON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212-1744
Practice Address - Country:US
Practice Address - Phone:313-369-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301501687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301501687OtherMI STATE LIC