Basic Information
| Provider Information | |||||||||
| NPI: | 1720052400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMENICK | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 BANNING ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199043485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026740600 | ||||||||
| FaxNumber: | 3026727144 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 CADMUS LN STE 205 | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216014094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108224553 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 07/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | C1-0006569 | DE | N | Other Service Providers | Specialist | 207Q00000X | C1-0006569 | DE | N | Allopathic & Osteopathic Physicians | Family Medicine | 208600000X | D92021 | MD | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.