Provider Demographics
NPI:1679211601
Name:DORNAIVIL, JOB
Entity Type:Individual
Prefix:
First Name:JOB
Middle Name:
Last Name:DORNAIVIL
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 1:6130 TOURS CT APT 105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4617
Mailing Address - Country:US
Mailing Address - Phone:302-390-7772
Mailing Address - Fax:
Practice Address - Street 1:6130 TOURS CT APT 105
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4617
Practice Address - Country:US
Practice Address - Phone:302-390-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21-177246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN121114371299Medicaid