Provider Demographics
NPI:1083723753
Name:OLSEN, MARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:OLSEN
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Gender:F
Credentials:MD
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Mailing Address - Street 1:3030 NORTH ST
Mailing Address - Street 2:SUITE 450
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1433
Mailing Address - Country:US
Mailing Address - Phone:409-832-9600
Mailing Address - Fax:409-832-9610
Practice Address - Street 1:3030 NORTH ST
Practice Address - Street 2:SUITE 450
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1433
Practice Address - Country:US
Practice Address - Phone:409-832-9600
Practice Address - Fax:409-832-9610
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2011-10-10
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Provider Licenses
StateLicense IDTaxonomies
TXG5447207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CI643Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE
TX00159XMedicare ID - Type UnspecifiedGROUP MEDICARE
TXC20042Medicare UPIN