Provider Demographics
NPI:1811053762
Name:DORN, HENRY HARTZOG III (MD)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:HARTZOG
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 1:405 LINDSAY ST
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4829
Mailing Address - Country:US
Mailing Address - Phone:336-889-2000
Mailing Address - Fax:336-889-2027
Practice Address - Street 1:405 LINDSAY STREET
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4829
Practice Address - Country:US
Practice Address - Phone:336-889-2000
Practice Address - Fax:336-889-2027
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000776174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891266KMedicaid
NC1266KOtherBCBS
NC891266KMedicaid