Healthcare Provider Details

I. General information

NPI: 1285622340
Provider Name (Legal Business Name): EDWARD DORAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 04/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 PARK AVE E SUITE 7
PRINCETON IL
61356-3901
US

IV. Provider business mailing address

530 PARK AVE E SUITE 7
PRINCETON IL
61356-3901
US

V. Phone/Fax

Practice location:
  • Phone: 815-875-8666
  • Fax: 815-872-0487
Mailing address:
  • Phone: 815-875-8666
  • Fax: 815-872-0487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036062499
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: