Provider Demographics
NPI:1902816903
Name:OLFUS, TAURA MICHELLE (DO)
Entity Type:Individual
Prefix:DR
First Name:TAURA
Middle Name:MICHELLE
Last Name:OLFUS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MISS
Other - First Name:TAURA
Other - Middle Name:MICHELLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14124 FOOTHILL BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-8051
Mailing Address - Country:US
Mailing Address - Phone:818-367-1012
Mailing Address - Fax:818-367-7570
Practice Address - Street 1:14124 FOOTHILL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-8051
Practice Address - Country:US
Practice Address - Phone:818-367-1012
Practice Address - Fax:818-367-7570
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2020-02-18
Deactivation Date:2006-08-22
Deactivation Code:
Reactivation Date:2006-09-15
Provider Licenses
StateLicense IDTaxonomies
CA20A9281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A9281OtherCA MED LIC
CA1902816903Medicaid
CAZZZ54049YOtherBS/TRIWEST
CA20A9281OtherCA MED LIC
CA1902816903Medicaid
CAAS743AMedicare PIN