Provider Demographics
NPI:1780790279
Name:DORN, RONALD V III (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:V
Last Name:DORN
Suffix:III
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-367-3131
Mailing Address - Fax:208-367-4860
Practice Address - Street 1:1055 N CURTIS ROAD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-367-3131
Practice Address - Fax:208-367-4860
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM46532085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004085400Medicaid
ID20001434Medicare PIN
IDD65703Medicare UPIN