Healthcare Provider Details

I. General information

NPI: 1396447025
Provider Name (Legal Business Name): THEODORE OLENICK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

IV. Provider business mailing address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-6806
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8871750
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: