Basic Information
| Provider Information | |||||||||
| NPI: | 1952442600 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OAK CREEK FAMILY PRACTICE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 PINEHURST DR | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804395906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 EDISON ST | ||||||||
| Address2: | |||||||||
| City: | BRUSH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807231640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 11/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | DILLON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | RANDY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PRESIDENT MD | ||||||||
| AuthorizedOfficialTelephone: | 7192760725 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35220 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 78054222 | 05 | CO | MEDICAID |