Provider Demographics
NPI:1831369255
Name:OLSON, MARK JEROME
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEROME
Last Name:OLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 MEDICAL CENTER CT STE 212
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6660
Mailing Address - Country:US
Mailing Address - Phone:619-216-9797
Mailing Address - Fax:
Practice Address - Street 1:752 MEDICAL CENTER CT STE 212
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6660
Practice Address - Country:US
Practice Address - Phone:619-216-9797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA396911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA39691OtherLICENSE NUMBER