Provider Demographics
NPI:1710997036
Name:DORMAN, JERRY S (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:S
Last Name:DORMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 DEAVER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5356
Mailing Address - Country:US
Mailing Address - Phone:479-751-3202
Mailing Address - Fax:479-756-2721
Practice Address - Street 1:724 DEAVER ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5356
Practice Address - Country:US
Practice Address - Phone:479-751-3202
Practice Address - Fax:479-756-2721
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARF2067208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106239001Medicaid
AR106239001Medicaid
AR51417Medicare PIN