Healthcare Provider Details

I. General information

NPI: 1952442600
Provider Name (Legal Business Name): OAK CREEK FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 11/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 EDISON ST
BRUSH CO
80723-1640
US

IV. Provider business mailing address

2550 PINEHURST DR
EVERGREEN CO
80439-5906
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35220
License Number StateCO

VIII. Authorized Official

Name: DR. ROBERT RANDY DILLON
Title or Position: OWNER PRESIDENT MD
Credential: MD
Phone: 719-276-0725