1609833110 NPI number — KRISTEN K DORMAN O.D.

Table of content: KRISTEN K DORMAN O.D. (NPI 1609833110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609833110 NPI number — KRISTEN K DORMAN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DORMAN
Provider First Name:
KRISTEN
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1609833110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 OLD GALLOWS RD STE 520
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22182-3970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-847-8899
Provider Business Mailing Address Fax Number:
571-223-6780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 MARTIN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDONIA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53021-9455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-692-9000
Provider Business Practice Location Address Fax Number:
262-692-2797
Provider Enumeration Date:
04/27/2006

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: 152W00000X , with the licence number:  2673-035 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 822601 . This is a "VIPA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38608200 . This is a "WI HEALTH INS RSK SHAR PR" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 391101335 . This is a "WI PHYS SERV WPS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 410041553 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 5300133 . This is a "AETNA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38608200 . This is a "ABRI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 103436 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 747042 . This is a "MOHAWK" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38608200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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