Provider Demographics
NPI:1104870708
Name:OLT, TAMARA L (MD)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:L
Last Name:OLT
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2850
Mailing Address - Country:US
Mailing Address - Phone:309-692-2805
Mailing Address - Fax:309-692-1913
Practice Address - Street 1:6915 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2850
Practice Address - Country:US
Practice Address - Phone:309-692-2805
Practice Address - Fax:309-692-1913
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089480207VX0000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL0101OtherJOHN DEERE HEALTH
IL343117OtherHEALTHLINK
ILP00289284/DE3835OtherRAILROAD MEDICARE
IL07232119OtherBCBS OF ILLINOIS
IL036089480Medicaid
IL036089480Medicaid
ILG35702Medicare UPIN