Provider Demographics
NPI:1043392012
Name:OLSON, MARK WARREN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WARREN
Last Name:OLSON
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 1:8750 OAK GROVE RD
Mailing Address - Street 2:
Mailing Address - City:RICKREALL
Mailing Address - State:OR
Mailing Address - Zip Code:97371-9766
Mailing Address - Country:US
Mailing Address - Phone:503-835-4001
Mailing Address - Fax:
Practice Address - Street 1:1160 WALLACE RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3116
Practice Address - Country:US
Practice Address - Phone:503-361-5400
Practice Address - Fax:503-361-5401
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR MD09591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR23416-1Medicaid
E10782Medicare UPIN
OR23416-1Medicaid