MEDICARE: ANDREI N DOKUKIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RA0401X	Addiction Medicine (Internal Medicine) Physician	A110631	CA
2	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	A110631	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A110631	OTHER	CA	STATE MEDICAL BOARD LICENSE
2	12086268	OTHER	CA	CAQH PROVIDER NUMBER

General Provider Information

NPI Number	:	1770715575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREI N DOKUKIN MD

Provider Business Mailing Address
First Line	:	1439 W CHAPMAN AVE # 46
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-2738
Country	:	US
Telephone Number	:	562-633-1765
Fax Number	:	949-502-8887

Provider Business Practice Location Address
First Line	:	3939 ATLANTIC AVE STE 223
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-3535
Country	:	US
Telephone Number	:	562-633-1765
Fax Number	:	949-502-8887

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2009
Last Update Date	:	03/24/2020

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