Provider Demographics
NPI:1669686135
Name:OLACK, JAMES BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:BRIAN
Last Name:OLACK
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 1:2450 E SHOW LOW LAKE RD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7953
Mailing Address - Country:US
Mailing Address - Phone:928-537-6767
Mailing Address - Fax:928-537-0299
Practice Address - Street 1:2450 E SHOW LOW LAKE RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7953
Practice Address - Country:US
Practice Address - Phone:928-537-6767
Practice Address - Fax:928-537-0299
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103523208200000X
AZ432222086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery