Provider Demographics
NPI:1558146001
Name:DORNG, BRADLEY
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:DORNG
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 1:2606 W 104TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-1605
Mailing Address - Country:US
Mailing Address - Phone:773-443-0815
Mailing Address - Fax:
Practice Address - Street 1:2606 W 104TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-1605
Practice Address - Country:US
Practice Address - Phone:773-443-0815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1105101-30163W00000X
IL041.465731163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse