Healthcare Provider Details

I. General information

NPI: 1902800873
Provider Name (Legal Business Name): WALTER HOLLIFIELD DORMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 FRANCE AVE S STE 5100
EDINA MN
55435
US

IV. Provider business mailing address

7600 FRANCE AVE S STE 5100
EDINA MN
55435-5924
US

V. Phone/Fax

Practice location:
  • Phone: 952-893-1959
  • Fax: 952-893-1954
Mailing address:
  • Phone: 952-893-1959
  • Fax: 952-893-1954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number21028
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: