Provider Demographics
NPI:1568423739
Name:DORMAN, NELLI G (MD)
Entity Type:Individual
Prefix:
First Name:NELLI
Middle Name:G
Last Name:DORMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 NOTCH BROOK RD
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545
Mailing Address - Country:US
Mailing Address - Phone:508-842-6069
Mailing Address - Fax:
Practice Address - Street 1:189 MAY STREET
Practice Address - Street 2:FAIRLAWN REHABILITATION HOSPITAL
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01602
Practice Address - Country:US
Practice Address - Phone:508-471-9302
Practice Address - Fax:508-753-2087
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60183207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9749471Medicaid
E78547Medicare UPIN
J10869Medicare ID - Type Unspecified