Provider Demographics
NPI:1154897924
Name:LAMELA DOMENECH, GUSTAVO ALFONSO
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ALFONSO
Last Name:LAMELA DOMENECH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:GUSTAVO
Other - Middle Name:
Other - Last Name:LAMELA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-353-4911
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:4660 S HAGADORN RD STE 500
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6804
Practice Address - Country:US
Practice Address - Phone:517-884-8701
Practice Address - Fax:517-884-8787
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR390200000X
390200000X
MI4301509093208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program