Healthcare Provider Details

I. General information

NPI: 1205915733
Provider Name (Legal Business Name): MARTIN J DOLAN III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BARRANCA PKWY STE 104
IRVINE CA
92604-8603
US

IV. Provider business mailing address

PO BOX 2757
ORANGE CA
92859-0757
US

V. Phone/Fax

Practice location:
  • Phone: 949-726-0677
  • Fax:
Mailing address:
  • Phone: 714-973-2650
  • Fax: 714-973-2655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG29683
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: