Healthcare Provider Details

I. General information

NPI: 1306936794
Provider Name (Legal Business Name): ALAN D OLMSTEAD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 WASHINGTON ST N STE 100
TWIN FALLS ID
83301
US

IV. Provider business mailing address

844 WASHINGTON ST N STE 100
TWIN FALLS ID
83301-3874
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-6800
  • Fax: 208-735-1635
Mailing address:
  • Phone: 208-734-6800
  • Fax: 208-735-1635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM-4775
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM4775
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: