Provider Demographics
NPI:1457439515
Name:OLCOTT, CORNELIUS IV (MD)
Entity Type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:
Last Name:OLCOTT
Suffix:IV
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:H-3636, VASCULAR CENTER
Mailing Address - Street 2:STANFORD UNIVERSITY MEDICAL CENTER
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305
Mailing Address - Country:US
Mailing Address - Phone:650-498-6036
Mailing Address - Fax:650-723-3600
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:STANFORD UNIVERSITY MEDICAL CENTER, H-3636
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-498-6036
Practice Address - Fax:650-723-3600
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG16297174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G162970Medicaid
CAA39762Medicare UPIN
CA00G162970Medicaid