Provider Demographics
NPI:1982774311
Name:THEODORE R. CORWIN, M.D., P.C.
Entity Type:Organization
Organization Name:THEODORE R. CORWIN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CORWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-494-3656
Mailing Address - Street 1:911 HAMPSHIRE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-2833
Mailing Address - Country:US
Mailing Address - Phone:805-494-3656
Mailing Address - Fax:805-778-9104
Practice Address - Street 1:911 HAMPSHIRE RD STE 1
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2833
Practice Address - Country:US
Practice Address - Phone:805-494-3656
Practice Address - Fax:805-778-9104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG291962086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG29196OtherBLUE CROSS PIN
CA00G291960OtherBLUE SHIELD PIN