Healthcare Provider Details

I. General information

NPI: 1124137187
Provider Name (Legal Business Name): ANTHONY JOSEPH DOMENIGONI D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/04/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 SE PARK PLAZA DR
VANCOUVER WA
98684-5886
US

IV. Provider business mailing address

15023 SE PEBBLE BEACH DR
HAPPY VALLEY OR
97086-7330
US

V. Phone/Fax

Practice location:
  • Phone: 360-449-7040
  • Fax:
Mailing address:
  • Phone: 503-698-2869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO00000777
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP00353
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: