Healthcare Provider Details

I. General information

NPI: 1962947317
Provider Name (Legal Business Name): MARK OLCOTT, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3609 LOTUS DR
SAN DIEGO CA
92106-1136
US

IV. Provider business mailing address

3609 LOTUS DR
SAN DIEGO CA
92106-1136
US

V. Phone/Fax

Practice location:
  • Phone: 619-261-7427
  • 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: DR. MARK OLCOTT
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 619-261-7427