Basic Information
| Provider Information | |||||||||
| NPI: | 1609833110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DORMAN | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MARTIN DR | ||||||||
| Address2: | |||||||||
| City: | FREDONIA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530219455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626929000 | ||||||||
| FaxNumber: | 2626922797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2673-035 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 822601 | 01 | WI | VIPA | OTHER | 38608200 | 01 | WI | WI HEALTH INS RSK SHAR PR | OTHER | 391101335 | 01 | WI | WI PHYS SERV WPS | OTHER | 410041553 | 01 | WI | RAILROAD MEDICARE | OTHER | 5300133 | 01 | WI | AETNA | OTHER | 38608200 | 01 | WI | ABRI | OTHER | 103436 | 01 | WI | HEALTH ALLIANCE | OTHER | 747042 | 01 | WI | MOHAWK | OTHER | 38608200 | 05 | WI | MEDICAID |