Provider Demographics
NPI:1356518831
Name:OLAVESON, TAIT DELL (DO)
Entity type:Individual
Prefix:DR
First Name:TAIT
Middle Name:DELL
Last Name:OLAVESON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277381
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 CHANNING WAY STE 206
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7546
Practice Address - Country:US
Practice Address - Phone:208-529-2230
Practice Address - Fax:208-453-6142
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-07262083P0011X, 208600000X
WY13411C208600000X
AK179881208600000X
GA82499208600000X
MT93936208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine