Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 28564 | MN |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 28564 | MN |
NPI | 1265474811 |
---|---|
Provider Name | Charles Dennis O'hare |
First Address | West Saint Paul, MN 55118-4441 |
Second Address | Stillwater, MN 55082-6788 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2006 |
Last Update Date | 31/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
417782700 | (05) | MN |
A94034 | (02) |