Healthcare Provider Details

I. General information

NPI: 1093753477
Provider Name (Legal Business Name): CHARLES DREYER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4597
US

IV. Provider business mailing address

777 BANNOCK ST
DENVER CO
80204-4597
US

V. Phone/Fax

Practice location:
  • Phone: 303-602-9250
  • Fax: 303-602-9262
Mailing address:
  • Phone: 303-602-9250
  • Fax: 303-602-9262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberDR.0074173
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberG6657
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: