Provider Demographics
NPI:1124170675
Name:DORN, BRADY ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:BRADY
Middle Name:ROBERT
Last Name:DORN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 THACKERAY TRL
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4342
Mailing Address - Country:US
Mailing Address - Phone:262-560-9600
Mailing Address - Fax:262-560-9599
Practice Address - Street 1:888 THACKERAY TRL
Practice Address - Street 2:SUITE 210
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4342
Practice Address - Country:US
Practice Address - Phone:262-560-9600
Practice Address - Fax:262-560-9599
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3622012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38933600Medicaid
WI38933600Medicaid