Provider Demographics
NPI:1922413657
Name:MARK H OLSEN DPM PLLC
Entity Type:Organization
Organization Name:MARK H OLSEN DPM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SOTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-234-8131
Mailing Address - Street 1:220 N STAPLEY DR
Mailing Address - Street 2:#1
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-8057
Mailing Address - Country:US
Mailing Address - Phone:623-234-8131
Mailing Address - Fax:623-234-8147
Practice Address - Street 1:220 N STAPLEY DR
Practice Address - Street 2:#1
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-8057
Practice Address - Country:US
Practice Address - Phone:623-234-8131
Practice Address - Fax:623-234-8147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0762213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ819643Medicaid