Basic Information
| Provider Information | |||||||||
| NPI: | 1427049683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMICZEK | ||||||||
| FirstName: | ALEKSANDER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6800 E 10 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CENTER LINE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480151167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866199986 | ||||||||
| FaxNumber: | 5868065085 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867832222 | ||||||||
| FaxNumber: | 5867836280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301048524 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0804400591 | 01 | MI | BLUE CROSS INDIVIDUAL | OTHER | 080D410020 | 01 | MA | COMMUNITY BLUE | OTHER | 253226 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | B43001 | 01 | MI | HEALTH NET FEDERAL | OTHER | 080D410020 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 92588990011 | 01 | MI | CIGNA | OTHER | 080162065 | 01 | MI | METRAHEALTH | OTHER | 080D410020 | 01 | MI | BLUE CROSS POS | OTHER | 4105744 | 01 | MI | AETNA | OTHER | 0805026931 | 01 | MI | BCN IND | OTHER | 080D410020 | 01 | MI | BLUE CARE NETWORK | OTHER | 253226 | 01 | MI | HEALTH ADVANTAGE NETWORK | OTHER | 4244111 | 05 | MI | MEDICAID | 0805026931 | 01 | MI | BCBS IND | OTHER | 0988917 | 01 | MI | HEALTH PLUS | OTHER | B43001 | 01 | MI | HEALTH ALLIANCE PLAN | OTHER | C7390 | 01 | MI | MCARE | OTHER | 1427049683 | 05 | MI | MEDICAID |