Basic Information
| Provider Information | |||||||||
| NPI: | 1194771469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOBKIN | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 23039 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911853039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622824038 | ||||||||
| FaxNumber: | 5626583397 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 PARKVIEW DR | ||||||||
| Address2: | |||||||||
| City: | LAURENS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293602652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8649840571 | ||||||||
| FaxNumber: | 8649843610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 20A8076 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 51708 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00AX80760 | 05 | CA | MEDICAID | 044862 | 01 | HEALHT NET ID # | OTHER | 020A80760 | 01 | BLUE SHIELD ID # | OTHER | 60066531 | 01 | RAILROAD | OTHER | 60066532 | 01 | RAILROAD | OTHER | 517088 | 05 | SC | MEDICAID |