Provider Demographics
NPI:1447515911
Name:PROPRIUS HEALTH MEDICAL GROUP PC
Entity type:Organization
Organization Name:PROPRIUS HEALTH MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREI
Authorized Official - Middle Name:N
Authorized Official - Last Name:DOKUKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-647-5031
Mailing Address - Street 1:3939 ATLANTIC AVE STE 223
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3535
Mailing Address - Country:US
Mailing Address - Phone:562-633-1765
Mailing Address - Fax:495-028-8879
Practice Address - Street 1:3939 ATLANTIC AVE STE 223
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807
Practice Address - Country:US
Practice Address - Phone:562-633-1765
Practice Address - Fax:949-502-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1106312081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D2048806OtherCLIA WAIVED CERTIFICATE
CAC3423023OtherSECRETARY OF STATE CORPORATION NUMBER
CAZZZ70684YOtherBLUE SHIELD OF CALIFORNIA GROUP PROVIDER NUMBER
CA43221OtherCA MEDICAL BOARD- FICTITIOUS NAME PERMIT
CACLR00343337OtherCA CLINICAL LAB REGISTRATION
CABU21223680OtherCITY OF LONG BEACH BUSINESS LICENSE
CACB208857Medicare PIN
CABU21223680OtherCITY OF LONG BEACH BUSINESS LICENSE