Provider Demographics
NPI:1609024470
Name:DORN, JONATHAN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SCOTT
Last Name:DORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6065 N TROPICAL TRL
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-7212
Mailing Address - Country:US
Mailing Address - Phone:321-863-4986
Mailing Address - Fax:321-453-3786
Practice Address - Street 1:6065 N TROPICAL TRL
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-7212
Practice Address - Country:US
Practice Address - Phone:321-863-4986
Practice Address - Fax:321-453-3786
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME376202085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC35126Medicare UPIN