Healthcare Provider Details

I. General information

NPI: 1811985658
Provider Name (Legal Business Name): MARK K OLGAARD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S MAIN ST
AU GRES MI
48703-8700
US

IV. Provider business mailing address

PO BOX 779
TAWAS CITY MI
48764-0779
US

V. Phone/Fax

Practice location:
  • Phone: 989-876-7104
  • Fax: 989-876-2881
Mailing address:
  • Phone: 989-362-0153
  • Fax: 989-362-4683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101008757
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: