Basic Information
| Provider Information | |||||||||
| NPI: | 1902300817 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36036 OVERLOOK PL | ||||||||
| Address2: | |||||||||
| City: | SELBYVILLE | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199754269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436907724 | ||||||||
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| Practice Location | |||||||||
| Address1: | 809 82ND PKWY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436921752 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2018 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | OS17729 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.