Provider Demographics
NPI:1609833110
Name:DORMAN, KRISTEN K (OD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:K
Last Name:DORMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:120 MARTIN DR
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:WI
Practice Address - Zip Code:53021-9455
Practice Address - Country:US
Practice Address - Phone:262-692-9000
Practice Address - Fax:262-692-2797
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2673-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI822601OtherVIPA
WI38608200OtherWI HEALTH INS RSK SHAR PR
WI391101335OtherWI PHYS SERV WPS
WI410041553OtherRAILROAD MEDICARE
WI5300133OtherAETNA
WI38608200OtherABRI
WI103436OtherHEALTH ALLIANCE
WI747042OtherMOHAWK
WI38608200Medicaid