Provider Demographics
NPI:1124137187
Name:DOMENIGONI, ANTHONY JOSEPH (DPM)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOSEPH
Last Name:DOMENIGONI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15023 SE PEBBLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-7330
Mailing Address - Country:US
Mailing Address - Phone:503-698-2869
Mailing Address - Fax:
Practice Address - Street 1:203 SE PARK PLAZA DR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5886
Practice Address - Country:US
Practice Address - Phone:360-449-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000777213ES0103X
ORDP00353213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery