Basic Information
| Provider Information | |||||||||
| NPI: | 1972590099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 PICCARD DR | ||||||||
| Address2: | STE 202 | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208504303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019217900 | ||||||||
| FaxNumber: | 3019217915 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 TOWN CENTER PKWY | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201903219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036899039 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 0101028312 | VA | Y | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | D0021940 | MD | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 7400 | 01 | CARE FIRST | OTHER |