Provider Demographics
NPI:1760423040
Name:DOBROWOLSKI, CHRISTINE CECYLIA (DPM)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:CECYLIA
Last Name:DOBROWOLSKI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1464 STERLING CT.
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150
Mailing Address - Country:US
Mailing Address - Phone:775-721-0677
Mailing Address - Fax:530-573-1496
Practice Address - Street 1:1626 MYRTLE AVE
Practice Address - Street 2:STE A
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501
Practice Address - Country:US
Practice Address - Phone:707-441-1112
Practice Address - Fax:707-441-1711
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4091213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E40910Medicaid
CA480025680OtherRAILROAD MEDICARE
CAU70466Medicare UPIN
CA000E40910Medicaid
CA000E40910Medicare ID - Type Unspecified