Provider Demographics
NPI:1215030333
Name:DORMAN, JOHN KYLE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KYLE
Last Name:DORMAN
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 1:540 W 5TH ST STE 320
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5002
Mailing Address - Country:US
Mailing Address - Phone:432-580-4700
Mailing Address - Fax:432-332-2678
Practice Address - Street 1:540 W 5TH ST STE 320
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5002
Practice Address - Country:US
Practice Address - Phone:432-580-4700
Practice Address - Fax:432-332-2678
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4342207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AJ418OtherBLUE CROSS BLUE SHIELD INDIVIDUAL NUMBER
TX166114201Medicaid
TX165059001Medicaid
TXL4342OtherPHYSICIAN LICENSE
TX0004QFOtherBCBS GROUP NUMBER
TX166114201Medicaid
TX760731730OtherEIN
TX165059001Medicaid
TXG56522Medicare UPIN