Provider Demographics
NPI:1356342661
Name:DOMINICK, TIMOTHY ROBERT (DPT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:DOMINICK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16310 SW PALERMO LN
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-0692
Mailing Address - Country:US
Mailing Address - Phone:503-577-0942
Mailing Address - Fax:
Practice Address - Street 1:16770 SW EDY RD STE 310
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9679
Practice Address - Country:US
Practice Address - Phone:503-216-9731
Practice Address - Fax:503-216-9732
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26238225100000X
OR51492251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5628499OtherFIRST HEALTH
CAZZZ01897ZOtherBLUE SHIELD
CAZZZ01897ZOtherBLUE SHIELD