Healthcare Provider Details

I. General information

NPI: 1407060080
Provider Name (Legal Business Name): SCOTT OLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 FIFER AVE # 2
CORTE MADERA CA
94925-1134
US

IV. Provider business mailing address

2 FIFER AVE STE 200
CORTE MADERA CA
94925-1174
US

V. Phone/Fax

Practice location:
  • Phone: 415-927-6695
  • Fax: 415-927-2179
Mailing address:
  • Phone: 415-927-6695
  • Fax: 415-927-2179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA46147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: