Provider Demographics
NPI:1427049683
Name:DOMICZEK, ALEKSANDER A (MD)
Entity type:Individual
Prefix:DR
First Name:ALEKSANDER
Middle Name:A
Last Name:DOMICZEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1167
Mailing Address - Country:US
Mailing Address - Phone:586-619-9986
Mailing Address - Fax:586-806-5085
Practice Address - Street 1:18 MARKET ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043
Practice Address - Country:US
Practice Address - Phone:586-783-2222
Practice Address - Fax:586-783-6280
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0804400591OtherBLUE CROSS INDIVIDUAL
MA080D410020OtherCOMMUNITY BLUE
MI253226OtherMCLAREN HEALTH PLAN
MIB43001OtherHEALTH NET FEDERAL
MI080D410020OtherBLUE CROSS BLUE SHIELD
MI92588990011OtherCIGNA
MI080162065OtherMETRAHEALTH
MI080D410020OtherBLUE CROSS POS
MI4105744OtherAETNA
MI0805026931OtherBCN IND
MI080D410020OtherBLUE CARE NETWORK
MI253226OtherHEALTH ADVANTAGE NETWORK
MI4244111Medicaid
MI0805026931OtherBCBS IND
MI0988917OtherHEALTH PLUS
MIB43001OtherHEALTH ALLIANCE PLAN
MIC7390OtherMCARE
MI1427049683Medicaid
MI0804400591OtherBLUE CROSS INDIVIDUAL
MI080D410020OtherBLUE CROSS POS
MI253226OtherHEALTH ADVANTAGE NETWORK
MIB43001Medicare UPIN