Provider Demographics
NPI:1720052400
Name:DOMENICK, MICHELE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:
Last Name:DOMENICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BANNING ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-3485
Mailing Address - Country:US
Mailing Address - Phone:302-674-0600
Mailing Address - Fax:302-672-7144
Practice Address - Street 1:500 CADMUS LN STE 205
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-4094
Practice Address - Country:US
Practice Address - Phone:410-822-4553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0006569174400000X, 207Q00000X
MDD92021208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine