Provider Demographics
NPI:1902108186
Name:LOUIS DVORKIN, PH.D. P.C.
Entity Type:Organization
Organization Name:LOUIS DVORKIN, PH.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DVORKIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-539-7747
Mailing Address - Street 1:6016 W MAPLE RD
Mailing Address - Street 2:SUITE 701
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4411
Mailing Address - Country:US
Mailing Address - Phone:248-539-7747
Mailing Address - Fax:248-539-7752
Practice Address - Street 1:4948 LAKE BLUFF CT
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2426
Practice Address - Country:US
Practice Address - Phone:248-539-7747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103G00103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F34726Medicare UPIN