Provider Demographics
NPI:1811924038
Name:DORFMAN, FRED LARRY (PHD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:LARRY
Last Name:DORFMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 LAKESIDE PARK
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-4020
Mailing Address - Country:US
Mailing Address - Phone:215-357-2380
Mailing Address - Fax:215-364-2437
Practice Address - Street 1:707 LAKESIDE PARK
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-4020
Practice Address - Country:US
Practice Address - Phone:215-357-2380
Practice Address - Fax:215-364-2437
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-004779-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARO7317Medicare UPIN
PA531523Medicare ID - Type Unspecified