Provider Demographics
NPI:1871896373
Name:MARK F. OLSEN M.D., P.A.
Entity type:Organization
Organization Name:MARK F. OLSEN M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-770-4100
Mailing Address - Street 1:439 E REDBUD LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3959
Mailing Address - Country:US
Mailing Address - Phone:479-770-4100
Mailing Address - Fax:479-770-0262
Practice Address - Street 1:212 W MONROE AVE STE B
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-9451
Practice Address - Country:US
Practice Address - Phone:479-770-4100
Practice Address - Fax:479-770-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
ARC6864261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5G789OtherMEDICARE PTAN
ARD04449Medicare UPIN