Provider Demographics
NPI:1538472766
Name:OLIDEN, MANDY STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:STEPHANIE
Last Name:OLIDEN
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 1:6601 W THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-5700
Mailing Address - Country:US
Mailing Address - Phone:602-243-7277
Mailing Address - Fax:623-247-9742
Practice Address - Street 1:6601 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-5700
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:623-247-9742
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ47956208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR72003OtherTRAINING PERMIT
AZ831983Medicaid