Provider Demographics
NPI:1861426983
Name:OLSON, GARY W (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:OLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1436 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3009
Mailing Address - Country:US
Mailing Address - Phone:706-226-3434
Mailing Address - Fax:706-226-4820
Practice Address - Street 1:1436 BROADRICK DR
Practice Address - Street 2:SUITE B
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3009
Practice Address - Country:US
Practice Address - Phone:706-226-3434
Practice Address - Fax:706-226-4820
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA020465207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000264745AMedicaid
GA335239OtherWELLCARE
TN4141465OtherTENN CARE
GA01410445OtherAMERIGROUP
GAP00859441OtherRR MEDICARE
GA01410445OtherAMERIGROUP
GAD40781Medicare UPIN