Provider Demographics
NPI:1447257209
Name:DORT, JONATHAN M (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:DORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3300 GALLOWS RD
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-3300
Mailing Address - Country:US
Mailing Address - Phone:703-776-4001
Mailing Address - Fax:703-776-7113
Practice Address - Street 1:8260 WILLOW OAKS CORPORATE DR STE 600
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4528
Practice Address - Country:US
Practice Address - Phone:571-472-4670
Practice Address - Fax:571-665-6798
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS0427231208600000X
VA0101245506208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100294940AMedicaid
KS051959Medicare ID - Type Unspecified