Healthcare Provider Details

I. General information

NPI: 1225488596
Provider Name (Legal Business Name): MARISSA DOMBOVY-JOHNSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 RIDGEWAY AVE STE 420
ROCHESTER NY
14626-4296
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-723-7972
  • Fax: 585-368-3119
Mailing address:
  • Phone: 585-723-7972
  • Fax: 585-368-3119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number310253
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: