Provider Demographics
NPI:1033314620
Name:OLSON, MIRA REGINA (MD)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:REGINA
Last Name:OLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:360 BROADWAY STE 100
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3979
Mailing Address - Country:US
Mailing Address - Phone:207-907-3550
Mailing Address - Fax:207-907-3562
Practice Address - Street 1:360 BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3900
Practice Address - Country:US
Practice Address - Phone:207-907-3550
Practice Address - Fax:207-907-3562
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2024-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD18537207RG0100X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1070564Medicaid