Provider Demographics
NPI:1801945746
Name:OLSON, TIMOTHY MARK I (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MARK
Last Name:OLSON
Suffix:I
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 18TH ST S
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6564
Mailing Address - Country:US
Mailing Address - Phone:701-234-0028
Mailing Address - Fax:
Practice Address - Street 1:3220 18TH ST S
Practice Address - Street 2:SUITE 2
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6564
Practice Address - Country:US
Practice Address - Phone:701-234-0028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND498111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16361Medicaid
NDN1275Medicare ID - Type UnspecifiedPROVIDER ID NUMBER