Healthcare Provider Details

I. General information

NPI: 1770715575
Provider Name (Legal Business Name): ANDREI N DOKUKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 ATLANTIC AVE STE 223
LONG BEACH CA
90807-3535
US

IV. Provider business mailing address

1439 W CHAPMAN AVE # 46
ORANGE CA
92868-2738
US

V. Phone/Fax

Practice location:
  • Phone: 562-633-1765
  • Fax: 949-502-8887
Mailing address:
  • Phone: 562-633-1765
  • Fax: 949-502-8887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberA110631
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA110631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: