Provider Demographics
NPI:1417918111
Name:DOMER, TIMOTHY P (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:P
Last Name:DOMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16687 SAINT CLAIR AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-9401
Mailing Address - Country:US
Mailing Address - Phone:330-385-4610
Mailing Address - Fax:330-385-4620
Practice Address - Street 1:16687 SAINT CLAIR AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-9401
Practice Address - Country:US
Practice Address - Phone:330-385-4610
Practice Address - Fax:330-385-4620
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005918D207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2000798000Medicaid
OH2069998Medicaid
OH2069998Medicaid
F77594Medicare UPIN