Healthcare Provider Details

I. General information

NPI: 1366524472
Provider Name (Legal Business Name): GARY S. OLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 GORDONVILLE RD STE 301
CAPE GIRARDEAU MO
63703-5095
US

IV. Provider business mailing address

PO BOX 801143
KANSAS CITY MO
64180-1143
US

V. Phone/Fax

Practice location:
  • Phone: 573-334-9641
  • Fax: 573-331-4130
Mailing address:
  • Phone: 573-331-5583
  • Fax: 573-331-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR3A32
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: