Provider Demographics
NPI:1346252525
Name:OLSON, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
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:PO BOX 2156
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-5156
Mailing Address - Country:US
Mailing Address - Phone:209-848-2273
Mailing Address - Fax:209-848-0242
Practice Address - Street 1:232 W F ST
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3844
Practice Address - Country:US
Practice Address - Phone:209-848-2273
Practice Address - Fax:209-848-0242
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40340207R00000X
CAG403400207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G403400Medicaid
CACA179077OtherMEDICARE PTAN
CACA179077OtherMEDICARE PTAN
CA00G403400Medicaid