Provider Demographics
NPI:1194771469
Name:DOBKIN, JACK E (DO)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:DOBKIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT LA 23039
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-3039
Mailing Address - Country:US
Mailing Address - Phone:562-282-4038
Mailing Address - Fax:562-658-3397
Practice Address - Street 1:106 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-2652
Practice Address - Country:US
Practice Address - Phone:864-984-0571
Practice Address - Fax:864-984-3610
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8076207RC0000X
SC51708207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX80760Medicaid
044862OtherHEALHT NET ID #
020A80760OtherBLUE SHIELD ID #
60066531OtherRAILROAD
60066532OtherRAILROAD
SC517088Medicaid
W20A8076DMedicare PIN
60066531OtherRAILROAD
020A80760OtherBLUE SHIELD ID #