Provider Demographics
NPI:1801804588
Name:DORNACKER, JON E (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:E
Last Name:DORNACKER
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 1:437 3RD AVE SE
Mailing Address - Street 2:PO BOX 09
Mailing Address - City:GARRISON
Mailing Address - State:ND
Mailing Address - Zip Code:58540-7235
Mailing Address - Country:US
Mailing Address - Phone:701-337-6714
Mailing Address - Fax:701-463-6543
Practice Address - Street 1:437 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:GARRISON
Practice Address - State:ND
Practice Address - Zip Code:58540-0009
Practice Address - Country:US
Practice Address - Phone:701-463-2245
Practice Address - Fax:701-463-6543
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND27263OtherBLUE CROSS/ BLUE SHIELD
ND13921Medicaid
ND712120Medicare Oscar/Certification
ND27263OtherBLUE CROSS/ BLUE SHIELD