Provider Demographics
NPI:1659717874
Name:DORMAN, MARK DALE
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DALE
Last Name:DORMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 MEI DR
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-5272
Mailing Address - Country:US
Mailing Address - Phone:707-565-4970
Mailing Address - Fax:
Practice Address - Street 1:3322 CHANATE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-1708
Practice Address - Country:US
Practice Address - Phone:707-565-4970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA555938163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse