Provider Demographics
NPI:1245222843
Name:OLSON, KATRINA M (MD)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:M
Last Name:OLSON
Suffix:
Gender:F
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:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:866-611-1512
Mailing Address - Fax:231-728-4789
Practice Address - Street 1:1877 N GETTY ST
Practice Address - Street 2:
Practice Address - City:N MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-8563
Practice Address - Country:US
Practice Address - Phone:231-728-5052
Practice Address - Fax:231-728-5086
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063121207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4556478Medicaid
MI4556478Medicaid