Provider Demographics
NPI:1255389979
Name:DORMITZER, PHILIP R (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:R
Last Name:DORMITZER
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 1:320 LONGWOOD AVE
Mailing Address - Street 2:ENDERS 673, CHILDREN'S HOSPITAL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5746
Mailing Address - Country:US
Mailing Address - Phone:617-355-3026
Mailing Address - Fax:
Practice Address - Street 1:320 LONGWOOD AVE
Practice Address - Street 2:ENDERS 673, CHILDREN'S HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5746
Practice Address - Country:US
Practice Address - Phone:617-355-3026
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA151131207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0110809Medicaid
MAG57217Medicare UPIN
MAA23029Medicare ID - Type Unspecified