Provider Demographics
NPI:1730279639
Name:OLSON, SCOTT J (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:J
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 1:606 E GOODE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:QUITMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75783-2567
Mailing Address - Country:US
Mailing Address - Phone:903-763-2421
Mailing Address - Fax:903-763-0812
Practice Address - Street 1:606 E GOODE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:QUITMAN
Practice Address - State:TX
Practice Address - Zip Code:75783-2567
Practice Address - Country:US
Practice Address - Phone:903-763-2421
Practice Address - Fax:903-763-0812
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLF079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8G6510OtherBC
TX153783901Medicaid
H20019Medicare UPIN
8080B9Medicare ID - Type Unspecified