Provider Demographics
NPI:1750601175
Name:DOLLY, DARREN ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:DARREN
Middle Name:ROBERT
Last Name:DOLLY
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:1215 LAWN AVE STE 100
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2493
Practice Address - Country:US
Practice Address - Phone:574-293-2893
Practice Address - Fax:574-293-1298
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074203A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN23604010OtherMEDICARE PTAN
IN201254340Medicaid
IN565800013OtherMEDICARE PTAN