Provider Demographics
NPI:1295999472
Name:NANCY DORMAN MD,PHD PLLC
Entity type:Organization
Organization Name:NANCY DORMAN MD,PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPC
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-944-1717
Mailing Address - Street 1:PO BOX 863
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39205-0863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1040 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9530
Practice Address - Country:US
Practice Address - Phone:601-933-5660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12674207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018785Medicaid
MS440000042Medicare PIN