Provider Demographics
NPI:1346518305
Name:DORN, MICHAEL P
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:P
Last Name:DORN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 N VICTORIA PARK RD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-3405
Mailing Address - Country:US
Mailing Address - Phone:954-566-4346
Mailing Address - Fax:
Practice Address - Street 1:2355 NE 26TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305-1628
Practice Address - Country:US
Practice Address - Phone:954-561-3880
Practice Address - Fax:954-564-6653
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist