Provider Demographics
NPI:1780778274
Name:OLSON, MARK DALE (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DALE
Last Name:OLSON
Suffix:
Gender:
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LAKE BLVD SOUTH
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313
Mailing Address - Country:US
Mailing Address - Phone:763-682-1849
Mailing Address - Fax:763-684-1864
Practice Address - Street 1:130 LAKE BLVD SOUTH
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313
Practice Address - Country:US
Practice Address - Phone:763-682-1849
Practice Address - Fax:763-684-1864
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2573111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN464528600Medicaid
MNC06871Medicare PIN
MN464528600Medicaid