Provider Demographics
NPI:1740090232
Name:DVORAK, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:DVORAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 S PEARL ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-2884
Mailing Address - Country:US
Mailing Address - Phone:970-481-1876
Mailing Address - Fax:
Practice Address - Street 1:3401 S LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2926
Practice Address - Country:US
Practice Address - Phone:720-838-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0020326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist