Provider Demographics
NPI:1285622340
Name:DORAN, EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:DORAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 PARK AVE E
Mailing Address - Street 2:SUITE 7
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-3901
Mailing Address - Country:US
Mailing Address - Phone:815-875-8666
Mailing Address - Fax:815-872-0487
Practice Address - Street 1:530 PARK AVE E
Practice Address - Street 2:SUITE 7
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-3901
Practice Address - Country:US
Practice Address - Phone:815-875-8666
Practice Address - Fax:815-872-0487
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062499207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062499Medicaid
ILL36879Medicare ID - Type Unspecified