Provider Demographics
NPI:1144254095
Name:AUSIELLO, DOMENICO S (MD)
Entity type:Individual
Prefix:
First Name:DOMENICO
Middle Name:S
Last Name:AUSIELLO
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 1:200 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-1740
Mailing Address - Country:US
Mailing Address - Phone:616-754-6949
Mailing Address - Fax:616-754-1062
Practice Address - Street 1:200 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-1740
Practice Address - Country:US
Practice Address - Phone:616-754-6949
Practice Address - Fax:616-754-1062
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2751016Medicaid
F01716Medicare UPIN
0590023Medicare PIN