Provider Demographics
NPI:1245627892
Name:DORMEVIL, RAYMOND (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:DORMEVIL
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 1:1701 TWIN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:HALETHORPE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-3553
Mailing Address - Country:US
Mailing Address - Phone:703-359-7878
Mailing Address - Fax:
Practice Address - Street 1:2125 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3001
Practice Address - Country:US
Practice Address - Phone:718-489-3557
Practice Address - Fax:718-489-3558
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1245627892Medicaid