Provider Demographics
NPI:1306936794
Name:OLMSTEAD, ALAN D
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:D
Last Name:OLMSTEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 WASHINGTON ST N STE 100
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3874
Mailing Address - Country:US
Mailing Address - Phone:208-734-6800
Mailing Address - Fax:208-735-1635
Practice Address - Street 1:844 WASHINGTON ST N STE 100
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-734-6800
Practice Address - Fax:208-735-1635
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4775174400000X
IDM4775207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001242700Medicaid
1116758Medicare ID - Type Unspecified