Provider Demographics
NPI:1669420949
Name:OLSON, LUCILA W (MD)
Entity type:Individual
Prefix:DR
First Name:LUCILA
Middle Name:W
Last Name:OLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:36500 S GRATIOT AVE
Practice Address - Street 2:STE. 101
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-1772
Practice Address - Country:US
Practice Address - Phone:586-493-3732
Practice Address - Fax:586-493-3739
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058057208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3225102Medicaid
MI350D410030OtherBCBS BCN COMM BLUE
MI3225096Medicaid
MI4956934Medicaid
MI1022817OtherMHP HAN
MI4682809Medicaid
MIG21966Medicare UPIN
MI3225102Medicaid