=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992808927
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DORI MIDDLEMAN M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 E LANCASTER AVE WYNNEWOOD HOUSE, SUITE 306B
-----------------------------------------------------
City | WYNNEWOOD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19096-2139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-664-7793
-----------------------------------------------------
Fax | 610-664-6667
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 MERBROOK LN
-----------------------------------------------------
City | MERION STATION
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19066-1617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-664-7793
-----------------------------------------------------
Fax | 610-664-6667
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | MD042136E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD042136E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------