Provider Demographics
NPI:1902800873
Name:DORMAN, WALTER HOLLIFIELD (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:HOLLIFIELD
Last Name:DORMAN
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 1:7600 FRANCE AVE S STE 5100
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5924
Mailing Address - Country:US
Mailing Address - Phone:952-893-1959
Mailing Address - Fax:952-893-1954
Practice Address - Street 1:7600 FRANCE AVE S STE 5100
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-893-1959
Practice Address - Fax:952-893-1954
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21028207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3200021OtherMEDICA
MN106158C477OtherUCARE
MN685592000Medicaid
MN965162OtherAFFORDABLE NETWORK
MNHP13178OtherHEALTHPARTNERS
MN66Q38DOOtherBLUE CROSS BLUE SHIELD
MN24909OtherAMERICA'S PPO
MN411774839A002OtherCHAMPUS
MN660003751OtherRR MEDICARE
MN960080460002OtherPREFERRED ONE