Provider Demographics
NPI:1740280510
Name:OLSSON-DETWILER, ALEKSANDRA (MD)
Entity type:Individual
Prefix:
First Name:ALEKSANDRA
Middle Name:
Last Name:OLSSON-DETWILER
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:PO BOX 132601
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-2601
Mailing Address - Country:US
Mailing Address - Phone:903-521-7838
Mailing Address - Fax:903-566-3297
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-521-7838
Practice Address - Fax:903-566-3297
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1685207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8P9640OtherBCBS
TX167741101Medicaid
TXP00151113OtherRAILROAD MEDICARE
TX8C2444Medicare PIN
TX8P9640OtherBCBS