Provider Demographics
NPI:1619976016
Name:DORAN, MARY E (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:DORAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 E BOUGHTON RD STE 195
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2194
Mailing Address - Country:US
Mailing Address - Phone:630-739-6610
Mailing Address - Fax:
Practice Address - Street 1:550 E BOUGHTON RD STE 195
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2194
Practice Address - Country:US
Practice Address - Phone:630-739-6610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005093213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005093Medicaid
ILP00954685Medicare PIN
IL016005093Medicaid
IL753600005Medicare PIN
ILP00954685Medicare PIN
ILU95805Medicare UPIN
IL560750010Medicare PIN