Provider Demographics
NPI:1942574942
Name:OLSON, GLEN ISAAC (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:ISAAC
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 1:4175 S ALAMO AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS MONTHAN AFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85707-4402
Mailing Address - Country:US
Mailing Address - Phone:301-312-4573
Mailing Address - Fax:
Practice Address - Street 1:4175 S. ALAMO AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85707
Practice Address - Country:US
Practice Address - Phone:301-312-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ58768207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine