Provider Demographics
NPI:1710397690
Name:DEWALD, OLGA GENNADYEVNA
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:GENNADYEVNA
Last Name:DEWALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLGA
Other - Middle Name:GENNADYEVNA
Other - Last Name:KUNSHINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1859 COBBLE CT
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7658
Mailing Address - Country:US
Mailing Address - Phone:248-252-5457
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-364-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105687207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine