Healthcare Provider Details

I. General information

NPI: 1538587704
Provider Name (Legal Business Name): JESSE DORAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3407 WILKENS AVE STE 300
BALTIMORE MD
21229-5222
US

IV. Provider business mailing address

3407 WILKENS AVE STE 300
BALTIMORE MD
21229-5222
US

V. Phone/Fax

Practice location:
  • Phone: 410-644-5111
  • Fax: 410-644-2715
Mailing address:
  • Phone: 585-784-9861
  • Fax: 585-427-8424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD91509
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberD91509
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number287413
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: