Provider Demographics
NPI:1265474811
Name:O'HARE, CHARLES DENNIS (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DENNIS
Last Name:O'HARE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1887 WINSLOW CT
Mailing Address - Street 2:
Mailing Address - City:WEST SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-4441
Mailing Address - Country:US
Mailing Address - Phone:612-819-5797
Mailing Address - Fax:
Practice Address - Street 1:270 MAIN ST N STE 300
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6788
Practice Address - Country:US
Practice Address - Phone:651-342-1039
Practice Address - Fax:651-342-1428
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28564207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN417782700Medicaid
MN080020914Medicare PIN
MN417782700Medicaid