Provider Demographics
NPI:1528176880
Name:DORNER, MATTHEW JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JAMES
Last Name:DORNER
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 1:3555 E CR 250 N
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938
Mailing Address - Country:US
Mailing Address - Phone:864-580-1676
Mailing Address - Fax:985-520-4352
Practice Address - Street 1:3555 E CR 250N
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938
Practice Address - Country:US
Practice Address - Phone:864-580-1676
Practice Address - Fax:217-728-8678
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036122714207Q00000X, 207Q00000X
SCMD 28142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6447860014Medicare NSC
ILIL3270109Medicare PIN