Basic Information
| Provider Information | |||||||||
| NPI: | 1902820525 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DVORAK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 TELEPHONE RD | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287624483 | ||||||||
| FaxNumber: | 2287690406 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 TELEPHONE RD | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287624483 | ||||||||
| FaxNumber: | 2287690406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 15891 | MS | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00339814 | 05 | MS | MEDICAID | P00054513 | 01 | MS | RAILROAD MEDICARE | OTHER |