1720123102 NPI number — VICTORIA S. DORGAN

Table of content: VICTORIA S. DORGAN (NPI 1720123102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720123102 NPI number — VICTORIA S. DORGAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DORGAN
Provider First Name:
VICTORIA
Provider Middle Name:
S.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720123102
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 BALCOM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02048-2010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 BALCOM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02048-2010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-261-1007
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 702925 . This is a "HARVARD PILGRIM HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 804276 . This is a "TUFTS SECURE HORIZON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 376454 . This is a "BLUE CROSS BLUE SHIELD MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1537083 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82-09709 . This is a "UNITED HEALTHCARE OF NE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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