Healthcare Provider Details

I. General information

NPI: 1790795540
Provider Name (Legal Business Name): MARTHA R DORN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2660 GRANT RD
MOUNTAIN VIEW CA
94040-4308
US

IV. Provider business mailing address

1965 BYRON ST
PALO ALTO CA
94301-4002
US

V. Phone/Fax

Practice location:
  • Phone: 650-962-4360
  • Fax:
Mailing address:
  • Phone: 650-328-4918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG65861
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: