Provider Demographics
NPI:1922730803
Name:DOMINOVIC, ANTONIO (RT(R)(CT)(ARRT))
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:DOMINOVIC
Suffix:
Gender:M
Credentials:RT(R)(CT)(ARRT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3414 SE 144TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-2709
Mailing Address - Country:US
Mailing Address - Phone:503-515-4985
Mailing Address - Fax:
Practice Address - Street 1:17744 NE SAN RAFAEL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-5927
Practice Address - Country:US
Practice Address - Phone:800-638-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60899550247100000X
OR9172832471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist