Provider Demographics
NPI:1508846353
Name:OLSON, KARL H (MD)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:H
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 1:465 MCKENNA DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-2143
Mailing Address - Country:US
Mailing Address - Phone:208-587-9703
Mailing Address - Fax:208-580-9812
Practice Address - Street 1:465 MCKENNA DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2143
Practice Address - Country:US
Practice Address - Phone:208-587-9703
Practice Address - Fax:208-580-9812
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM 6548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F 94150Medicare UPIN
1130814Medicare ID - Type Unspecified