Provider Demographics
NPI:1902820525
Name:DVORAK, EDWARD I (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:I
Last Name:DVORAK
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 1:2525 TELEPHONE RD
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567
Mailing Address - Country:US
Mailing Address - Phone:228-762-4483
Mailing Address - Fax:228-769-0406
Practice Address - Street 1:2525 TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567
Practice Address - Country:US
Practice Address - Phone:228-762-4483
Practice Address - Fax:228-769-0406
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15891208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00339814Medicaid
MSP00054513OtherRAILROAD MEDICARE
G05536Medicare UPIN
MS020000478Medicare PIN