Provider Demographics
NPI:1306832670
Name:OLM, PATRICIA M (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:M
Last Name:OLM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:M
Other - Last Name:GODFREY-OLM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:1050 N SAN FRANCISCO ST
Practice Address - Street 2:STE B
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3259
Practice Address - Country:US
Practice Address - Phone:928-214-3737
Practice Address - Fax:928-214-3837
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22349207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
738093OtherHUMANA
AZ809202Medicaid
AZAZ0379910OtherBLUE CROSS BLUE SHIELD
F82920Medicare UPIN
AZZ62097Medicare PIN
AZ809202Medicaid