Provider Demographics
NPI:1659724649
Name:CARLA DORMER MD PLLC
Entity Type:Organization
Organization Name:CARLA DORMER MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-343-2900
Mailing Address - Street 1:5110 N 44TH ST
Mailing Address - Street 2:SUITE L200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-1649
Mailing Address - Country:US
Mailing Address - Phone:602-343-2900
Mailing Address - Fax:602-391-2080
Practice Address - Street 1:5110 N 44TH ST
Practice Address - Street 2:SUITE L200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-1649
Practice Address - Country:US
Practice Address - Phone:602-343-2900
Practice Address - Fax:602-391-2080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37374207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ155689Medicare PIN