Provider Demographics
NPI:1447278122
Name:DORMAN, BRIAN WALLACE (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:WALLACE
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 1:2576 RENFREN STREET
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501
Mailing Address - Country:US
Mailing Address - Phone:707-445-3257
Mailing Address - Fax:707-445-1027
Practice Address - Street 1:2576 RENFREN STREET
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501
Practice Address - Country:US
Practice Address - Phone:707-445-3257
Practice Address - Fax:707-445-1027
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24506208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A42282Medicare UPIN
CA00G245060Medicare ID - Type Unspecified