Healthcare Provider Details

I. General information

NPI: 1255999215
Provider Name (Legal Business Name): IAN DWORKIN, M.D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 W COAST HWY STE A
NEWPORT BEACH CA
92663-4025
US

IV. Provider business mailing address

1130 LAKE ST APT 2
VENICE CA
90291-3112
US

V. Phone/Fax

Practice location:
  • Phone: 949-491-9991
  • Fax:
Mailing address:
  • Phone: 610-547-9449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: IAN DWORKIN
Title or Position: DIRECTOR
Credential: MD
Phone: 949-491-9991