Healthcare Provider Details

I. General information

NPI: 1669474417
Provider Name (Legal Business Name): MARK VERNON OLCOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10666 N TORREY PINES RD
LA JOLLA CA
92037-1027
US

IV. Provider business mailing address

3609 LOTUS DR
SAN DIEGO CA
92106-1136
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-5100
  • Fax:
Mailing address:
  • Phone: 619-261-7427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA55234
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: