Provider Demographics
NPI:1699734129
Name:OLSON, GARY C (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:C
Last Name:OLSON
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 1:1441 W CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1707
Mailing Address - Country:US
Mailing Address - Phone:563-383-1900
Mailing Address - Fax:563-884-4256
Practice Address - Street 1:1441 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1707
Practice Address - Country:US
Practice Address - Phone:563-383-1900
Practice Address - Fax:563-884-4256
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA187142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0247460Medicaid
IA0247460Medicaid
10312Medicare PIN
IA24746Medicare ID - Type UnspecifiedBCBS