Provider Demographics
NPI:1841457389
Name:OLSON, BRETTA M (MD)
Entity type:Individual
Prefix:DR
First Name:BRETTA
Middle Name:M
Last Name:OLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BRETTA
Other - Middle Name:MAY
Other - Last Name:SCHUMACHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-945-5246
Mailing Address - Fax:605-945-5295
Practice Address - Street 1:100 MAC LN
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-224-5901
Practice Address - Fax:605-945-5295
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1844208000000X
SD8144390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6702620Medicaid
SD105198Medicare PIN