Provider Demographics
NPI:1376283697
Name:OLSON, ELIZABETH MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
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 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:JBSA FT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-4789
Mailing Address - Fax:210-916-6654
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-4789
Practice Address - Fax:210-916-6654
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0072158208D00000X
CODR.0072158208D00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice