Provider Demographics
NPI:1568452811
Name:DOMBROSKE, OLAN C (DO)
Entity type:Individual
Prefix:MR
First Name:OLAN
Middle Name:C
Last Name:DOMBROSKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7115 CADE RD
Mailing Address - Street 2:
Mailing Address - City:BROWN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48416-9778
Mailing Address - Country:US
Mailing Address - Phone:810-346-2757
Mailing Address - Fax:810-346-2016
Practice Address - Street 1:7115 CADE RD
Practice Address - Street 2:
Practice Address - City:BROWN CITY
Practice Address - State:MI
Practice Address - Zip Code:48416-9778
Practice Address - Country:US
Practice Address - Phone:810-346-2757
Practice Address - Fax:810-346-2016
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0D008339 5101008339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0157600104OtherBLUE CROSS BLUE SHIELD
MI1626158Medicaid
E26464Medicare UPIN
5760010Medicare ID - Type Unspecified