Basic Information
Provider Information | |||||||||
NPI: | 1538587704 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DORAN | ||||||||
FirstName: | JESSE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3407 WILKENS AVE | ||||||||
Address2: | STE 300 | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212295222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5857849861 | ||||||||
FaxNumber: | 5854278424 | ||||||||
Practice Location | |||||||||
Address1: | 3407 WILKENS AVE | ||||||||
Address2: | STE 300 | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212295222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106445111 | ||||||||
FaxNumber: | 4106442715 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2014 | ||||||||
LastUpdateDate: | 02/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | D91509 | MD | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 208M00000X | 287413 | NY | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207RC0000X | D91509 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.