Healthcare Provider Details

I. General information

NPI: 1508822701
Provider Name (Legal Business Name): OLIVER N DOLD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEMORIAL DR STE 207
DECATUR IL
62526-3950
US

IV. Provider business mailing address

2300 N EDWARD ST GSBLL
DECATUR IL
62526-4163
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-2780
  • Fax: 217-876-2785
Mailing address:
  • Phone: 217-876-2780
  • Fax: 217-876-2785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number036090811
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: