Basic Information
Provider Information | |||||||||
NPI: | 1922168863 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOMINGO | ||||||||
FirstName: | ALFREDO | ||||||||
MiddleName: | CANLAS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3532 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | DECKERVILLE | ||||||||
State: | MI | ||||||||
PostalCode: | 484279615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8106480561 | ||||||||
FaxNumber: | 8106483352 | ||||||||
Practice Location | |||||||||
Address1: | 74 S ELK ST | ||||||||
Address2: |   | ||||||||
City: | SANDUSKY | ||||||||
State: | MI | ||||||||
PostalCode: | 484711354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8106484229 | ||||||||
FaxNumber: | 8106484217 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2006 | ||||||||
LastUpdateDate: | 05/11/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4301044325 | MI | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.