Healthcare Provider Details

I. General information

NPI: 1245306067
Provider Name (Legal Business Name): MARY L OLSEN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3070 COLLEGE STREET SUITE 205
BEAUMONT TX
77701
US

IV. Provider business mailing address

3070 COLLEGE STREET SUITE 205
BEAUMONT TX
77701
US

V. Phone/Fax

Practice location:
  • Phone: 409-832-9600
  • Fax: 409-832-9610
Mailing address:
  • Phone: 409-832-9600
  • Fax: 409-832-9610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberTEXASG5447
License Number StateTX

VIII. Authorized Official

Name: DR. MARY L OLSEN
Title or Position: PRESIDENT
Credential: MD
Phone: 409-832-9600