Provider Demographics
NPI:1497733315
Name:OLSON, DAVID STANLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:STANLEY
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 1:3537 W FRONT ST
Mailing Address - Street 2:STE G
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7941
Mailing Address - Country:US
Mailing Address - Phone:231-935-8822
Mailing Address - Fax:231-935-8837
Practice Address - Street 1:3537 W FRONT ST
Practice Address - Street 2:STE G
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7941
Practice Address - Country:US
Practice Address - Phone:231-935-8822
Practice Address - Fax:231-935-8837
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045961208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1540536Medicaid
F10151Medicare UPIN
MI0281014Medicare ID - Type Unspecified