Provider Demographics
NPI:1063501930
Name:DIMAGNO, MONICA M (MD)
Entity type:Individual
Prefix:MS
First Name:MONICA
Middle Name:M
Last Name:DIMAGNO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:585 SOUTH BLVD E STE 100
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-3163
Mailing Address - Country:US
Mailing Address - Phone:248-206-1200
Mailing Address - Fax:734-615-9505
Practice Address - Street 1:2211 OLD EARHART RD STE 195
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2963
Practice Address - Country:US
Practice Address - Phone:734-615-9200
Practice Address - Fax:734-615-9205
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065992207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3469117Medicaid
MI0D76010014Medicare ID - Type Unspecified
MI3469117Medicaid