Provider Demographics
NPI:1427363506
Name:DORN MEDICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:DORN MEDICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:DORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-544-5325
Mailing Address - Street 1:193 NURSERY RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-4847
Mailing Address - Country:US
Mailing Address - Phone:850-544-5325
Mailing Address - Fax:850-386-9161
Practice Address - Street 1:193 NURSERY RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-4847
Practice Address - Country:US
Practice Address - Phone:850-544-5325
Practice Address - Fax:850-386-9161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD17696Medicare UPIN