Provider Demographics
NPI:1780630103
Name:OLLE, ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:OLLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3699
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-8699
Mailing Address - Country:US
Mailing Address - Phone:714-378-5330
Mailing Address - Fax:714-378-5320
Practice Address - Street 1:18255 BROOKHURST ST
Practice Address - Street 2:100
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6771
Practice Address - Country:US
Practice Address - Phone:714-378-5330
Practice Address - Fax:714-378-5320
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A7981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH88971Medicare UPIN