Provider Demographics
NPI:1417001041
Name:DOMROSE, DANIEL SCOTT (DPM)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:SCOTT
Last Name:DOMROSE
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 1:2440 NW PROFESSIONAL DR
Mailing Address - Street 2:TIMBER HILL FOOT CLINIC DANIEL S DOMROSE DPM
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330
Mailing Address - Country:US
Mailing Address - Phone:541-754-9665
Mailing Address - Fax:541-758-5706
Practice Address - Street 1:2440 NW PROFESSIONAL DR
Practice Address - Street 2:TIMBER HILL FOOT CLINIC DANIEL S DOMROSE DPM
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-754-9665
Practice Address - Fax:541-758-5706
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00264213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR073119Medicaid
ORDP00264OtherSTATE LICENSE
OR073119Medicaid
0000SBGMNMedicare ID - Type Unspecified