Provider Demographics
NPI:1013954585
Name:KANDAH, DOMIAN (DO)
Entity Type:Individual
Prefix:
First Name:DOMIAN
Middle Name:
Last Name:KANDAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4308
Mailing Address - Fax:
Practice Address - Street 1:11800 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-573-5059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI008716207PE0004X
MI5101008716207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI112905533Medicaid
MI114218327Medicaid
MI112905758Medicaid
OH2791439Medicaid
MI112905749Medicaid
OH000000552888OtherANTHEM/BCBS
MI114206077Medicaid
OHP00427186OtherMEDICARE RAILROAD
MIDK008716OtherBLUE SHIELD
MI112905533Medicaid
OHP00427186OtherMEDICARE RAILROAD
MI112905758Medicaid