Provider Demographics
NPI:1093089187
Name:DOMER, JOHANNA KANERVA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:KANERVA
Last Name:DOMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 E CACTUS RD
Mailing Address - Street 2:SUITE 940
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-4163
Mailing Address - Country:US
Mailing Address - Phone:480-443-0050
Mailing Address - Fax:
Practice Address - Street 1:4848 E CACTUS RD
Practice Address - Street 2:SUITE 940
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4163
Practice Address - Country:US
Practice Address - Phone:480-443-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29475208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics