Provider Demographics
NPI:1942389770
Name:DOMER, TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:DOMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 N FORBES BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1412
Mailing Address - Country:US
Mailing Address - Phone:520-872-7536
Mailing Address - Fax:520-872-7929
Practice Address - Street 1:1601 W SAINT MARYS RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2623
Practice Address - Country:US
Practice Address - Phone:520-872-6040
Practice Address - Fax:520-872-6007
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23789207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ407678Medicaid
AZH51217Medicare UPIN