Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RA0401X | Internist - Addiction Medicine | A110631 | CA |
Y | 2081P2900X | Pain Medicine | A110631 | CA |
NPI | 1770715575 |
---|---|
Provider Name | Andrei N Dokukin |
First Address | Orange, CA 92868-2738 |
Second Address | Long Beach, CA 90807-3535 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2009 |
Last Update Date | 24/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12086268 | CAQH PROVIDER NUMBER (01) | CA |
A110631 | STATE MEDICAL BOARD LICENSE (01) | CA |