Provider Demographics
NPI:1538343298
Name:JOHN M. DORN
Entity type:Organization
Organization Name:JOHN M. DORN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DORN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:219-322-4066
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-0248
Mailing Address - Country:US
Mailing Address - Phone:219-322-4066
Mailing Address - Fax:
Practice Address - Street 1:944 RICHARD RD
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1936
Practice Address - Country:US
Practice Address - Phone:219-322-4066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000629A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL90000913OtherBLUE CROSS/BLUE SHIELD
IN100202200Medicaid
IL480007478OtherRAILROAD MEDICARE
IN5436006OtherAETNA
IN480019631OtherRAILROAD MEDICARE
IN000000095590OtherANTHEM
IN628050Medicare PIN
IN000000095590OtherANTHEM
IL90000913OtherBLUE CROSS/BLUE SHIELD
IN0477580001Medicare NSC