MEDICARE: DR. MARK JEROME OLSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	39691	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	39691	OTHER	CA	LICENSE NUMBER

General Provider Information

NPI Number	:	1831369255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK JEROME OLSON

Provider Business Mailing Address
First Line	:	752 MEDICAL CENTER CT STE 212
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-6660
Country	:	US
Telephone Number	:	619-216-9797
Fax Number	:

Provider Business Practice Location Address
First Line	:	752 MEDICAL CENTER CT STE 212
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-6660
Country	:	US
Telephone Number	:	619-216-9797
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2008
Last Update Date	:	03/03/2008

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