Provider Demographics
NPI:1548330269
Name:DORN, JOHN MICHAEL (DPM)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:DORN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:944 RICHARD RD.
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:219-322-2691
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:219-322-2691
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000629A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5436006OtherAETNA
IN000000095590OtherANTHEM
IL60001634OtherBCBS OF IL FOR IL OFFICE
IN100202200Medicaid
IL90000913OtherBCBS OF IL FOR IN OFFICE
IN480019631Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IL90000913OtherBCBS OF IL FOR IN OFFICE
T39086Medicare UPIN
IL480007478Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IN000000095590OtherANTHEM
IN0477580001Medicare NSC