Provider Demographics
NPI:1154353357
Name:OLTERMANN, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:OLTERMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 HEMPHILL ST
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4709
Mailing Address - Country:US
Mailing Address - Phone:817-702-3381
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-921-3431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8323207R00000X, 207RC0200X
NV16376207RC0200X
MTMED-PHYS-LIC-76336207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150942401Medicaid
OK200003780AMedicaid
NM59339837Medicaid
TX8757K6Medicare ID - Type Unspecified
NM59339837Medicaid