Provider Demographics
NPI:1134173594
Name:OLSEN, YNGVILD (MD, MPH)
Entity type:Individual
Prefix:
First Name:YNGVILD
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-5612
Mailing Address - Country:US
Mailing Address - Phone:410-750-6080
Mailing Address - Fax:
Practice Address - Street 1:2104 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5612
Practice Address - Country:US
Practice Address - Phone:410-750-6080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD57871207R00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD699117300Medicaid
MD699117300Medicaid
MDKR65JHMedicare ID - Type UnspecifiedGROUP