Provider Demographics
NPI:1578872776
Name:DORKHOM, STEPHAN JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:JOSEPH
Last Name:DORKHOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 HAMBURG TPKE STE 202
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2149
Mailing Address - Country:US
Mailing Address - Phone:973-310-0309
Mailing Address - Fax:
Practice Address - Street 1:234 HAMBURG TPKE STE 202
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2149
Practice Address - Country:US
Practice Address - Phone:973-310-0309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09656200207RH0003X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ60168529OtherHORIZON NJ HEALTH
NM75902036Medicaid
NJ0546747Medicaid
TX8DV048OtherBCBS
NM75902036Medicaid
TX218174502Medicaid