Provider Demographics
NPI:1255441952
Name:PSOLKA, MAXIMILIAN (MD)
Entity type:Individual
Prefix:DR
First Name:MAXIMILIAN
Middle Name:
Last Name:PSOLKA
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 1:4878 S HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6007
Mailing Address - Country:US
Mailing Address - Phone:801-272-8861
Mailing Address - Fax:
Practice Address - Street 1:4878 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-6007
Practice Address - Country:US
Practice Address - Phone:801-272-8861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047658A207W00000X
MDD70499207W00000X
WAMD61291718207W00000X
UT1143296-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD036676500Medicaid
MD036676500Medicaid