Provider Demographics
NPI:1043254626
Name:OLSON, MARK WALTER (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WALTER
Last Name:OLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1504 SAND POINT ROAD
Mailing Address - Street 2:
Mailing Address - City:MUNISING
Mailing Address - State:MI
Mailing Address - Zip Code:49862
Mailing Address - Country:US
Mailing Address - Phone:906-387-4220
Mailing Address - Fax:906-387-5449
Practice Address - Street 1:1504 SAND POINT ROAD
Practice Address - Street 2:
Practice Address - City:MUNISING
Practice Address - State:MI
Practice Address - Zip Code:49862
Practice Address - Country:US
Practice Address - Phone:906-387-4220
Practice Address - Fax:906-387-5449
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIXX27082OtherHEALTH PLUS
MI0800217331OtherBLUECARE NETWORK PIN
MIMO058238OtherBLUE CROSS LICENSE
MI0800217331OtherBLUE CROSS PIN
MIQMXPR0017426OtherMOLINA HEALTHCARE PIN
MI4301058238OtherSTATE OF MI MEDICAL LICEN
MI4840017Medicaid
MI05670OtherMCLAREN HEALTH PLAN PIN
MI383165248101OtherMI COMMUNITY CHOICE PIN
MI383165248101OtherMI COMMUNITY CHOICE PIN
MI4840017Medicaid
BO1545396OtherDEA