Provider Demographics
NPI:1861443939
Name:MARSALESE, DOMINIC L (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:L
Last Name:MARSALESE
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 1:27901 WOODWARD AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-0919
Mailing Address - Country:US
Mailing Address - Phone:248-545-0070
Mailing Address - Fax:248-545-4850
Practice Address - Street 1:27901 WOODWARD AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-0919
Practice Address - Country:US
Practice Address - Phone:248-545-0070
Practice Address - Fax:248-545-4850
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048140207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC03461Medicare UPIN
MI0F36306Medicare ID - Type Unspecified
MIC03461Medicare UPIN