Provider Demographics
NPI:1942279815
Name:HOMNICK, DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:HOMNICK
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 1:3299 GULL RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1281
Mailing Address - Country:US
Mailing Address - Phone:269-373-5259
Mailing Address - Fax:269-373-5292
Practice Address - Street 1:3299 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1281
Practice Address - Country:US
Practice Address - Phone:269-373-5259
Practice Address - Fax:269-373-5292
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010497802080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1942279815Medicaid
MI4200108Medicaid
3513924451OtherBCBS
MI4200108Medicaid
MI0C3609229Medicare PIN