Provider Demographics
NPI:1073683405
Name:CORWIN, THEODORE R (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:R
Last Name:CORWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 HAMPSHIRE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-2818
Mailing Address - Country:US
Mailing Address - Phone:805-494-3656
Mailing Address - Fax:805-778-9104
Practice Address - Street 1:911 HAMPSHIRE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2818
Practice Address - Country:US
Practice Address - Phone:805-494-3656
Practice Address - Fax:805-778-9104
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG291962086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA77-0210292OtherTIN
CA77-0210292OtherTIN
CAA91177Medicare UPIN