Healthcare Provider Details

I. General information

NPI: 1083241293
Provider Name (Legal Business Name): KODY DUANE DORMIRE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

400 E CEDAR ST
PERRY OK
73077-7833
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-4940
  • Fax:
Mailing address:
  • Phone: 580-336-7670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036162380
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036162380
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: