Provider Demographics
NPI:1891738852
Name:DOMMER, MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:DOMMER
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 1:125 S KALAMAZOO MALL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-4832
Mailing Address - Country:US
Mailing Address - Phone:269-343-3900
Mailing Address - Fax:269-343-5640
Practice Address - Street 1:125 S KALAMAZOO MALL
Practice Address - Street 2:SUITE 204
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-4832
Practice Address - Country:US
Practice Address - Phone:269-343-3900
Practice Address - Fax:269-343-5640
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067676207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10/4457925Medicaid
MI10/4450423Medicaid
MI104686919Medicaid
MI10/4450423Medicaid
MIH00009Medicare UPIN
MIP08090014Medicare ID - Type UnspecifiedALLEGAN
MI104686919Medicaid