Provider Demographics
NPI:1417024654
Name:DORMADY, SHANE PAUL (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:PAUL
Last Name:DORMADY
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4127
Mailing Address - Country:US
Mailing Address - Phone:650-988-8338
Mailing Address - Fax:650-962-4594
Practice Address - Street 1:2505 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4127
Practice Address - Country:US
Practice Address - Phone:650-988-8338
Practice Address - Fax:650-962-4594
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87232207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A872320Medicaid
CA00A872321OtherMEDICARE RAILROAD
CA00A872321Medicare PIN
CA00A872320Medicaid