Provider Demographics
NPI:1225020746
Name:OLSON, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:OLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:29900 LORRAINE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5266
Mailing Address - Country:US
Mailing Address - Phone:586-582-0864
Mailing Address - Fax:586-582-0964
Practice Address - Street 1:11012 E 13 MILE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2572
Practice Address - Country:US
Practice Address - Phone:586-573-6880
Practice Address - Fax:586-573-2562
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010448662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1997933Medicaid
MI700E021830OtherBCBS
MI700F340300OtherBCBS
MIMO044866OtherBCBS PIN #
MI700E021910OtherBCBS
MI700E021830OtherBCBS
MI700E021910OtherBCBS
MIMO044866OtherBCBS PIN #