Provider Demographics
NPI:1114203700
Name:DVORAK, MAREK C (PHD)
Entity Type:Individual
Prefix:
First Name:MAREK
Middle Name:C
Last Name:DVORAK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6610 GUNPARK DR
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3460
Mailing Address - Country:US
Mailing Address - Phone:720-636-4409
Mailing Address - Fax:
Practice Address - Street 1:6610 GUNPARK DR
Practice Address - Street 2:SUITE 101B
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3460
Practice Address - Country:US
Practice Address - Phone:720-636-4409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY0004303103TC0700X
CAPSY27642103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416Medicare PIN