Provider Demographics
NPI:1568432888
Name:OLLIE, STEVEN B (MD)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:B
Last Name:OLLIE
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 1:164466 PLUM RD.
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607
Mailing Address - Country:US
Mailing Address - Phone:208-455-0461
Mailing Address - Fax:
Practice Address - Street 1:201 S 1ST AVE E
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-5809
Practice Address - Country:US
Practice Address - Phone:208-585-6311
Practice Address - Fax:208-585-6221
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4429207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDB63601Medicare UPIN