Provider Demographics
NPI:1356425722
Name:DAVID K. DORMAN, MD SC
Entity type:Organization
Organization Name:DAVID K. DORMAN, MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:K
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-782-4144
Mailing Address - Street 1:19475 W NORTH AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4199
Mailing Address - Country:US
Mailing Address - Phone:262-782-4144
Mailing Address - Fax:262-782-5854
Practice Address - Street 1:19475 W NORTH AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4199
Practice Address - Country:US
Practice Address - Phone:262-782-4144
Practice Address - Fax:262-782-5854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16979-020208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30203100Medicaid
WIB52489Medicare UPIN