Provider Demographics
NPI:1053339432
Name:DORFMAN, JUSTIN NATHANIEL (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:NATHANIEL
Last Name:DORFMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1215
Mailing Address - Country:US
Mailing Address - Phone:508-460-3250
Mailing Address - Fax:
Practice Address - Street 1:24 NEWTON ST
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1215
Practice Address - Country:US
Practice Address - Phone:508-460-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226691207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2115441Medicaid
MAA39963Medicare PIN