Provider Demographics
NPI:1366430316
Name:DORMU, JEFFERY JAWNI (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:JAWNI
Last Name:DORMU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:8730 CHERRY LANE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707
Mailing Address - Country:US
Mailing Address - Phone:301-497-1590
Mailing Address - Fax:240-334-4781
Practice Address - Street 1:8730 CHERRY LANE
Practice Address - Street 2:SUITE 10
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707
Practice Address - Country:US
Practice Address - Phone:301-497-1590
Practice Address - Fax:240-334-4781
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MB07611900208600000X
MDH0065639208600000X, 2086S0129X
DCDO034245208600000X
DCD00342452086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD031107300Medicaid
NJ0048615Medicaid
DC054737700Medicaid
150945ZDKPMedicare Oscar/Certification
NJI22877Medicare UPIN
DC054737700Medicaid