Provider Demographics
NPI:1962947317
Name:MARK OLCOTT, M.D., INC.
Entity type:Organization
Organization Name:MARK OLCOTT, M.D., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:OLCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-261-7427
Mailing Address - Street 1:3609 LOTUS DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-1136
Mailing Address - Country:US
Mailing Address - Phone:619-261-7427
Mailing Address - Fax:
Practice Address - Street 1:3609 LOTUS DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-1136
Practice Address - Country:US
Practice Address - Phone:619-261-7427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55234207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty