Provider Demographics
NPI:1548263049
Name:OLSON, MARK R (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:OLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:CO
Mailing Address - Zip Code:80821-0248
Mailing Address - Country:US
Mailing Address - Phone:719-743-2421
Mailing Address - Fax:719-743-2084
Practice Address - Street 1:111 6TH STREET
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:CO
Practice Address - Zip Code:80821
Practice Address - Country:US
Practice Address - Phone:719-743-2421
Practice Address - Fax:719-743-2084
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO25806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01258060Medicaid
CO7967-4Medicare ID - Type Unspecified
CO01258060Medicaid