Provider Demographics
NPI:1053581470
Name:CHARLES K. DAHLGREN, M.D., CORP
Entity type:Organization
Organization Name:CHARLES K. DAHLGREN, M.D., CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:DAHLGREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-738-2555
Mailing Address - Street 1:1995 ERRECART BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-8336
Mailing Address - Country:US
Mailing Address - Phone:775-738-2555
Mailing Address - Fax:
Practice Address - Street 1:1995 ERRECART BLVD STE 109
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-8336
Practice Address - Country:US
Practice Address - Phone:775-738-2555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA20663OtherCALIFORNIA STATE LICENSE
A22258OtherUPIN
P00273393OtherRR MEDICARE
101836OtherMEDICARE
NV100507648Medicaid
NV11563OtherNEVADA STATE LICENSE